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SCOTIA COAL MINE DISASTER
MARCH 9 AND 11, 1976
A STAFF REPORT
OCTOBER 15, 1976
This report has not been officially adopted by the Committee on
Education and Labor (or the Subcommittee on Labor Standards) and
may not therefore necessarily reflect the the views of its members
Prepared by the staff of the House Committee on Education and Labor,
Subcommittee on Labor Standards, John H. Dent, Chairman
U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 1976
COMMITTi;i: ON EDUCATION AND LABOR
FRANK THOMPSON, Jb., New Jersey
John ii. DENT, Pennyslvania
DOMINICK v. DANIELS, New Jersey
John BRADEMAS, [ndlana
JAME8 G. O'HARA, Michigan
A.UQUBTUS F. HAWKINS, California
WILLIAM I). FOR I), Michigan
PATSY T. MINK, Hawaii (onleave)
LLOYD MEEDS, Washington
PHILLIP BURTON, California
JOSEPH M. QAYDOS, Pennsylvania
WILLIAM "HILL" CLAY, Missouri
SHIRLEY CHISHOLM,New York
MARK) BIAOGI, New York
IKK ANDREWS, North Carolina
WILLIAM LEHMAN, Florida
JAIME BENITEZ, Puerto Rico
ROBERT CORNELL, Wisconsin
PA CTL SIMON. Illinois
EDWARD BEARD, Rhode Island
LEO ZEFERETTI.New York
GEORGE MILLER, California
RONALD MOTTL, Ohio
TIM HALL, Illinois
PERKINS, Kentucky, Chairman
ALBERT H.QUIE, Minnesota
JOHN M. ASHBROOK, Ohio
ALPHONZO BELL, California
JOHN N. ERLENBORN, Illinois
MARVix L. ESCH, Michigan
EDWIN D. ESHLEMAN, Pennsylvania
PETER A. PEYSER, New York
RONALD A. SARASIN, Connecticut
JOHN B QC HANAN, Alabama
JAMES M. JEFFORDS. Vermont
LARRY PRESSLER, South Dakota
WILLIAM F. GOODLING, Pennsylvania
VIRGINIA SMITH, Nebraska
Subcommittee on Labor Standards
DOMINICK V. DANIELS, New Jersey
PHILLIP BURTON, California
JOSEPH M. GAYDOS, Pennsylvania
WILLIAM "BILL" CLAY, Missouri
MARIO BIAGGI, New York
JAIME BENITEZ, Puerto Rico
LEO ZEFERETTI, New York
GEORGE MILLER, California
ROBERT CORNELL, Wisconsin
FAIL SIMON. Illinois
CARL D. PERKINS, Kentucky,
JOHN N. ERLENBORN, Illinois
RONALD A. SARASIN, Connecticut
JOHN M. ASHBROOK, Ohio
ALPHONZO BELL, California
WILLIAM GOODLING, Pennsylvania
ALBERT H. QUIE, Minnesota,
I. Introduction and summary 1
II. Background and chronology of events 6
III. Safety history of the Scotia Mine 10
IV. MESA's enforcement efforts at the Scotia Mine 15
V. The March 9 and March 11, 1976, explosions at the Scotia Mine 33
Scotia Coal Mine:
Summary of violation notices and closure orders, May 13, 1970-
March9, 1976 53
Summary of safety and health violations, January 1974- February
Summary of ventilation violations, January 1974-February 1976 53
Digitized by the Internet Archive
Introduction and Summary
On March 9, 1976, at 11:35 A.M., dangerous concentrations of
methane gas accumulated in a poorly ventilated section of the Scotia
Coal Mine and was ignited by an unknown source. The coal mine
explosion that resulted killed 15 miners. Again, on March 11, 1976,
at about 11 :20 P.M., the same conditions combined in the same section
of the Scotia mine to cause a second explosion in which another 11 men
died. Thus, within a 60-hour period, 26 men lost their lives in the
bowels of the Scotia coal mine, located near Oven Fork, in Eastern
Kentucky. As of this date, the bodies of the 11 men killed in the second
explosion remain entombed in the mine.
Why did Scotia happen? This same question was asked of the
Farmington disaster in 1968 which claimed the lives of 78 coal miners;
the Hyden disaster of 1970 which killed 38 miners; and the Itmann
and Blackville disasters of 1972 in which 14 died.
In 1969, the U.S. Congress responded to the Farmington disaster by
enacting the Federal Coal Mine Health and Safety Act, which is,
perhaps, the strongest such law in the world. Since the passage of the
Federal Coal Mine Health and Safety Act of 1969, over 1,000 coal
miners have died in mine explosions, roof falls, and other coal mine
Why did Scotia happen? Since the disaster, the House Education
and Labor Committee, under the direction of Chairman Carl Perkins
and Labor Standards Subcommittee Chairman John H. Dent, has been
searching for answers and insights into the Scotia tragedy. In con-
junction with the Senate Committee on Labor and Public Welfare,
the Committee held three days of public hearings in Washington, D.C.
and Whitesburg, Kentucky. The Committee heard from Scotia widows,
miners, company officials, outside professionals, and Federal Govern-
ment officials. The Committee and its staff reviewed thousands of
pages of testimony, conducted individual interviews, and analyzed
mine inspection reports and other related documents.
In order to inform the full Committee, and the public at-large, as
to what has been learned thus far about the Scotia disaster, Mr.
Perkins and Mr. Dent instructed the staff to prepare this report. The
views contained herein are those of the majority staff, and do not
necessarily represent those of the Committee.
Why did Scotia happen? While all the causal factors related to the
disaster have yet to be conclusively determined, the available evidence
strongly supports the following conclusions :
1. The Scotia Coal Company, in effect, ignored the require-
ments of the Federal Coal Mine Health and Safety Act, its
standards and administrative regulations;
2. The Mining Enforcement and Safety Administration
(MESA) failed to effectively enforce the Federal Coal Mine
Health and Safety Act at the mine;
Ultimate responsibility for the first explosion of March 9,
1976, rests with the Scotia Coal Company, but responsibility for
the second explosion of March 11, 1976, must, in the staff's
opinion, rest with M ESA.
The Scotia Coal Mine, near Oven Fork, Kentucky, was known as
one of the most dangerous mines in the United States and the most
gassy mine in Eastern Kentucky. In addition, the Scotia mine had a
long and chronic history of Federal coal mine health and safety viola-
tion-. From 1970 to 1976, the Scotia mine had been ordered closed
] 10 separate times — 39 times for imminent danger conditions. During
this same period, some S55 notices for Federal health and safety
violations had been issued against the company. In the period January
1974 to February 1976, the mine had been cited for 63 separate viola-
tions of Federal ventilation and methane standards.
In addition, the record contains evidence that:
• The Scotia mine's ventilation plan was regularly violated
and, at the time of the first explosion, Scotia was in violation of
its ventilation plan;
• At various times, methane readings taken by the company
officials had registered as high as 9 percent;
© The required 20 minute methane monitoring regulation was
repeatedly violated and seldom adhered to at the Scotia mine;
• Required preshift mine inspections for hazardous ventilation,
methane and other conditions were not regularly conducted at
the Scotia mine: preshift inspection reports were routinely falsi-
fied; and the section of the mine which exploded had not been
inspected prior to the shift in which the first explosion occurred;
• A methane gas feeder which measured at least 5 percent had
existed in that section of the mine which exploded ;
• The company's safety education and training program was a
sham, and no one, including the company's safety inspector, could
remember the last time a fire or mine evacuation drill had been
conducted at the Scotia mine. Six of the 15 miners killed in the
first explosion suffocated to death.
From the record, it is clear that the Scotia mine was a bad mine, a
dangerous mine, a mine with a long and chronic history of health and
safety violations. It was a mine which in our opinion placed production
and profit before the safety and health of its miners. It was a mine
which essentially ignored the law.
In the staff's opinion, the Scotia mine was permitted to operate in
disregard of the law primarily because MESA failed to adequately and
effectively enforce the Coal Mine Health and Safety Act in such a
manner so as to effectuate lasting and permanent compliance. MESA
failed to test its imminent danger authority to determine whether —
based upon a mine's prior history of violations — the operation of a
mine like Scotia, in-and-of-itself, could be considered as imminently
dangerous and therefore ordered closed until such time that the
chronic safety and health problems were permanently abated. Aside
from failing to t"st its imminent danger authority, MESA also failed to
effectively use its established mine closure authority to impress upon
Scotia th' 4 severity of its mine safety and health problems. Although
prior to the explosion MESA closed the mine 1 10 times, the record in-
dicates that the overwhelming majority of these closure orders were
lifted the same day they wore issued, thus having a minimal effect on
production. While MESA had the authority to repeatedly close the
Scotia mine for unwarrantable failure to comply with health and safety
standards, the record shows that MESA used this authority sparingly.
In the 15 month period prior to the explosions, Scotia violated the
Federal ventilation standards 33 times, but MESA only issued 4
unwarrantable failure to comply closure orders, all of which were
lifted the same day they were issued. Even though Scotia's safety
record indicated willful and knowing violations, MESA never once
brought criminal charges against the Company.
In terms of the assessment and collection of monetary fines, MESA's
record at Scotia was abominable. The record indicates that monetary
penalty assessments were low to begin with, and the amounts actually
collected were even lower; as much as 50 percent lower. On only three
occasions did MESA ever assess the maximum civil penalty of $10,000
against Scotia; two of these cases involved deaths and the other
involved serious physical injuries. Only one of the death cases has been
resolved, and MESA settled out of court for $5,500; a reduction of 45
percent. The highest penalty ever assessed against Scotia for a ventila-
tion violation was $582 of which MESA only collected $291 ; a reduc-
tion of 50 percent. MESA's monetary penalty record at the Scotia
mine indicates that both assessments and collections were neither
progressive nor cumulative. As a matter of fact the record shows that
as Scotia continued to violate the law, both assessed and collected
amounts either remained the same or were lower than previous amounts
for similar violations.
The history of MESA inspection efforts at the Scotia mine indicates
serious shortcomings including an over-reliance on one-man spot
inspections; poor procedures for reviewing and evaluating ventilation
plans; and inadequate information systems. Since 1970, MESA has
conducted some 225 one-man spot inspections of the Scotia mine com-
pared to only 23 "regular" inspections of the entire mine. Spot
inspections check only for limited conditions in a short period of time.
The day before the first explosion, MESA conducted a limited inspec-
tion of the Scotia mine which failed to include that section of the mine
where both explosions occurred. At the time of the first explosion,
Scotia was in violation of its ventilation plan for more than a month,
yet MESA was unaware of the violation until a week before the first
explosion and, even then, failed to take any action. MESA's informa-
tion system was such that local MESA officials failed to adequately use
the information they had on the history of violations at the Scotia
mine, and the flow of this information never reached top MESA
Thus, when viewed in its entirety, MESA's enforcement record at
the Scotia mine was one of ineffectiveness. Nothing more clearly
demonstrates this ineffectiveness than the fact that after some 1,000
man days of inspection and enforcement activity, the Scotia mine
continued to be operated as an unsafe and dangerous mine.
In terms of the explosions themselves, all of the causal factors have
yet to be fully determined. However, it is known that both explosions
occurred in the same section of the jnine; the 2 Southeast main section.
In addition, there is a general consensus that both explosions resulted
from an explosive build-up of methane gas which accumulated in the
poorly ventilated 2 Southeast main section and was ignited by an
With respect to the first explosion of March 9th, the record supports
the following findings:
1. The nature of the MESA inspection on March 8th, less than 24
hours before the first explosion, was limited in both purpose and scope
and did not include that section of the mine where the explosion
occurred 2 Southeast main.
2. That section of the mine which exploded — 2 Southeast main — was
not subjected to the required preshift mine examination prior to two
locomotives (operated by two Scotia miners killed in the explosion)
entering the section on the morning of March 9th. The explosion
occurred minutes after the locomotives — one fitted with a questionable
air compressor — entered 2 Southeast main.
3. About a month before the explosion, Scotia temporarily dis-
continued active mining in 2 Southeast main, and initiated production
in the 2 Left panel, off 2 Southeast main. This new production violated
Scotia's approved ventilation plan and may have interrupted the
4. A methane gas feeder was known to exist near the face of 2
5. Ventilation problems were experienced in the 2 Left panel, off 2
Southeast main, both the day before and immediately prior to the
6. Scotia officials engaged in questionable practices in an effort to
"correct" the ventilation problems uncovered in the March 8th
7. While the exact source of ignition has yet to be determined,
there is some evidence to support the conclusion that the ignition was
somehow related to the activity of the two locomotives entering the
2 Southeast main section: Most of the explosion-related mine damage
was reported to be in the immediate area of the two locomotives, and
the explosion occurred only minutes after the locomotives entered
2 Southeast main.
8. Six of the fifteen miners who were killed on March 9th survived
the initial explosion but subsequently suffocated to death after their
self-rescue equipment became inoperable. Professional testimony
indicated that these six men probably could have saved themselves by
simply walking out of the mine following the initial blast.
Within a few hours of the first explosion, MESA officials assumed
effective control of the Scotia mine and directed all the rescue, re-
covery and investigation efforts. Throughout this period MESA was
responsible for all decisions and actions related to the Scotia mine
disaster. It was MESA officials who made the decision to send a 13-
man work crew into the mine on March 11, to repair a damaged roof
and to restore ventilation. At 11:20 P.M. on March 11, this 13-man
crew v n> caught in the second Scotia explosion which, like the first
explosion, originat ed in the 2 Southeast main section of the mine.
Eleven men died in the blast and two survived.
With respect to the environmental conditions in the mine between
the two explosions, the following is known:
• Nearly all the physical mine damage resulting from the first
explosion was found in the area of the two locomotives located
in the upper portions of 2 Southeast main;
• Dangerous concentrations of methane gas and carbon monoxide
were found in 2 Southeast main by the rescue teams on March
• Work crews and rescue teams on March 9-10 were unable to
restore ventilation to the 2 Southeast main section ;
• A hazardous roof condition was found at the entrance to 2
• Perhaps most importantly, the upper portions of 2 Southeast
main were not inspected or firebossed for hazardous conditions.
From the time the rescue teams recovered the bodies of the two
locomotive men, killed in the first explosion, until now, no one
has been in the 2 Southeast main section of the Scotia mine. Thus,
at the time the 13-man work crew approached the entrance to 2
Southeast main to repair the damaged roof on March 11, the
hazardous environmental conditions in 2 Southeast main were
As in the case of the first explosion, the ignition source of the second
explosion has yet to be determined. However, unlike the first explo-
sion, there is evidence indicating that the responsible MESA officials
failed to seriously consider at least one possible ignition source that
was known to exist prior to the second explosion — one of the loco-
motives fitted with a questionable air compressor.
This machine, a Goodman locomotive, was one of the locomotives
sent into that section of the mine which exploded on March 9. The air
compressor on the Goodman locomotive was an integral part of the
machine's braking system and automatically "kicked on" when the
air pressure dropped below a certain point. According to testimony,
the compressor "kicked on" automatically about every 15 to 20
minutes, and whenever engaged it caused a substantial spark which
was more than sufficient to ignite an explosive concentration of
methane gas. This locomotive-compressor, which could have caused
the first explosion, remained in the mine following the initial explosion
and remains there today.
In terms of the decisions made by MESA in the period between
explosions, the most critical decision was to send the 13-man work
crew back into the mine on March 11, after previous attempts to
restore ventilation in 2 Southeast main had failed. The hearing
record strongly suggests that this decision was made simply as a
matter of routine and without due regard for the possible hazards
involved. Prior to the men entering the mine on March 11, MESA
officials knew that something was wrong with the ventilation in
2 Southeast main; they knew of dangerous concentrations of methane
in that section; they knew of the Goodman locomotive; and they
knew that 2 Southeast main had not been subject to a preshift ex-
amination ; yet the fateful decision was made with little or no thought
given to these factors, and the work crew was sent into the mine
without any instructions as to the possible hazards involved.
Why did Scotia happen? In the opinion of the committee staff the
Scotia coal mine disasters of March 9 and March 11, 1976 had their
roots in the past practices of the Scotia Coal Company. The disasters
happened because MESA failed to effectively enforce" the law at the
Scotia coal mine. The March 9th explosion happened because deadly
concentrations of methane gas were permitted to accumulate in a
poorly ventilated section of the mine where men were sent to work.
The March l lth explosion occurred because MESA failed to adequate-
ly consider the possible hazards involved in men working near the
mine section where ventilation had not been restored and which
evidenced explosive concentration- of met bane gas.
Throughout the bearings conducted by the House Education and
Labor Comn. .d the Senate Labor and Public Welfare Com-
mittee. MESA officials repeatedly stated that as coal mines go, the
Scotia min; 4 was not considered as particularly hazardous. If this i-
true: if there are coal mines which are more dangerous than Scotia and
with safety and health records as bad as Scotia'-, then how many more
Scotia- are out there just waiting to explode? Must our coal miners
simply rely on fate and good luck each time they go into a coal mine?
The Congress, in 1969, enacted the Coal Mine Health and Safety Act
in order to replace luck and fate with strong and vigorous preventive
measures. The law was enacted to prevent coal mine explosions, roof
falls and other accidents which since 1969 have claimed over 1,000
lives and injured thousands more.
The Coal Mine Health and Safety Act is a good law, it is a strong
and progressive law. But the law is only as good, as strong and as
progressive as its enforcement. As this report documents, enforcement
of the Coal Mine Health and Safety Act at the Scotia mine was neither
vigorous nor effective. We sincerely hope that when all the factors
related to the Scotia disaster are finally determined, that effective
government action will be taken to prevent another Scotia.
Background and Chronology of Events: Scotia Coal Mine
Disasters, March 9 and March 11, 1976
Blue Diamond Coal Company Inc. is a Knoxville, Tennessee firm
that produces about 2.3 million tons of coal a year in Kentucky. It
is the parent company of the Scotia Coal Company whose No. 1
mine under Black Mountain in Letcher County exploded on March 9
and March 11, 1976, killing 26 men.
The Blue Diamond Company is headquartered at 6205 Kingston
Pike, Knoxville, Tennessee. The top corporate officers of the parent
firm and the two wholly owned affiliates are Joseph W. Hoffman,
president; Gordon Bonnyman, board chairman; and R. H. Watson,
vice president for operations. Blue Diamond is the selling agent for
the Company's six coal brands; Leatherwood, Blue Diamond, Royal
Scott, Starfire, Mayflower, and Tennessee Group.
Blue Diamond's oldest and largest Kentucky operation is at
Leatherwood in Perry County, near the boundaries of Harlan and
Leslie Counties. It acquired the Scotia property in 1962 and started
operations in three seams in 1963. Two seams are above drainage
and considered "non-gassy" by state standards. The No. 1 seam is
below drainage and has long been classified as "gassy."
The Company has recognized the Southern Labor Union (SLIT) as
its bargaining agent at Leatherwood. However, miners at the Scotia
Coal Company are represented by the Scotia Employees Association.
Access at the Scotia Mine No. 1 into the Imboden coal seam is
achieved through one 400-foot deep mine shaft. Air circulation is
forced into the mine by a fan circulating approximately 200,000
cubic feet of air per minute through the mine. Intake air comes into
the mine at two locations. Coal is mined by continuous miners and is
transported by shuttle cars onto conveyors. Permissible battery-
powered equipment is used for transporting the men from the surface
to the working places in the mine. The Scotia mine liberates in the
range of 200,000 to 500,000 cubic feet of methane per 24 hours, with
the most active production of methane being at the mining faces.
The explosions which occurred on March 9 and March 11, 1976, oc-
curred in the 2 Southeast main (2 SEM) section of the mine.
January-February 1976. — MESA conducted an 8-week inspection
of entire Scotia No. 1 mine.
February 1976. — Mining in 2 Southeast main (2 SEM) section was
discontinued due to the height of the coal seam and lack of equipment.
Mining machinery was moved back from the face of 2 SEM and mining
was begun in the 2 Left panel, off 2 SEM.
March 1976. — Scotia submitted to M.E.S.A. a proposed new ventila-
tion plan for the mine.
March 8, 1976, 2nd shift— M.E.S.A. Coal Mine Health Technical
Specialist Cecil Davis, stationed at Whitesburg, Kentucky made an
inspection of the 2 Left panel, off 2 SEM. Davis issued 4 notices of
violations, 2 of which were for ventilation problems. Davis, did not
inspect 2 SEM.
March S-9, 1976, 3rd shift. — Scotia fire boss Charles Fields conducted
a preshift examination of Scotia mine but failed to inspect 2 SEM.
March 9, 1976
During the morning, two miners were sent into 2 SEM to take
steel rails into the section for storage. Two locomotives were used to
push steel loaded cars into the area.
11 a.m. — James Bentley, Assistant mine foreman in charge of
ventilation, noticed a regulator governing air intake had been left
open, thereby changing ventilation patterns in mine. Bentley closed
11:15 a.m. — Bentley called the mine foreman, and aked for a ventila-
tion check. Bentley then called Virgil Coots, foreman on 2 Left panel
off 2 SEM and asked for air reading. Coots said he "just lost" his
ventilation. Bentley told him to check his curtains and call him back.
Time about 11:30.
11:35 a.m. — First Explosion occurred in 2 SEM.
12:26 p.m.— Scotia reported accident to M.E.S.A.'s Whitesburg,
Kentucky office as ignition.
12:45 p.m. — Scotia informed M.E.S.A. of an explosion with 16
men unaccounted for; M.E.S.A. Inspectors were dispatched.
12:50 p.m.— M.E.S.A.'s Pikeville office notified M.E.S.A. national
office in Arlington, Virginia of the accident.
> 1:10 p.m.— M.E.S.A. inspectors at mine issued 103(f) order, effec-
tively controlling entry into Scotia mine.
3 p.m. — Scotia personnel attempted rescue efforts but failed to
make any progress.
3 p.m. — First mine rescue teams arrived; Other teams continued to
arrive until 11:00 p.m. that evening.
3:15 p.m. — M.E.S.A. officials Monroe West, Subdistrkt Manager,
Norton, Kentucky office and William Clemons, Assistant District
Manager Pikeville, Kentucky office arrived at the mine. Charles
Sample, M.E.S.A. Coal Mine Inspection Supervisor, Harlan, Kentucky
arrived soon after. West and Sample went underground to direct
rescue operations; Clemons took charge on the surface.
4:30 p.m. — First mine rescue team went underground.
4:35 p. 7n. — Second mine rescue team went underground.
6:55 p.m. — First fresh air base established.
S:30 p.m. — M.E.S.A. Administrator Robert Barrett, Assistant Ad-
ministrator John Crawford, and R. Peluso, Assistant Administrator
Technical Support, arrived at the mine, After briefing, all three went
10 p.m. — Barrett and company arrived at the fresh air base and
began assisting in the operations.
10:15 p.m. — First body was found in area of 2 SEM by the West-
moreland Coal Company rescue team.
March 10, 1076
1:20 a.m. — All 15 bodies were located and removed. Five bodies were
located in main shaft of 2 SEM at the intersection of 2 Left panel, and
eight bodies were discovered behind a makeshift curtain barricade in
the 2 Left panel. Two bodies were discovered by National Mine Rescue
team farther up 2 SEM towards face near the two locomotives. Mine
area in the vicinity of the locomotives which was described as show-
ing the most damage.
4:46 a.m. — The bodies arrived at the surface. All personnel were
withdrawn from mine.
Early morning hours. — A meeting of M.E.S.A., state, company
officials and miners was held to decide future actions. It was decided
that M.E.S.A. rescue teams and Scotia personnel would work during
the 2nd shift to restore ventilation to mine. It was also agreed to
reenter mine for an inspection tour beginning at 7:00 A.M. on 3—11—
76. After this meeting, M.E.S.A. Washington personnel departed.
7:30-8 a.m. — William Clemons went home; Russell Tackett of
M.E.S.A. was left in charge. Clemons returned to mine later in the day,
prior to 2nd shift, and resumed control.
5 p.m. — At the suggestion of Ben Taylor, M.E.S.A. Coal Mine
Inspection Supervisor, Whitesburg, Kentucky, Taylor and Richard
Combs, Scotia General mine foreman, began to pre-shift inspect
part of mine (not up 2 SEM). Taylor was told by Combs of a com-
pressor on a locomotive near face of 2 SEM. Taylor asked Combs if
locomotive-compressor could have been a possible ignition source.
Taylor did not immediately report this conversation to other officials.
6:55 p.m.. — Two M.E.S.A. teams entered the mine to reestablish
ventilation and explore 2 SEM. They discovered a hazardous roof con-
dition. They also determined that ventilation would be difficult to
12:48 a.m. — M.E.S.A. teams returned to the surface and reported
the roof condition and ventilation problems.
2:05 a.m. — Company, M.E.S.A. and State officials met to decide
future course of action. At the meeting, it was decided to postpone
a proposed inspection tour until roof repairs were made and ventilation
restored. It was decided to begin the repair work on 2nd shift, later
in the day.
4 a.m. — William Clemons left the mine; John South and John
Banks, two M.E.S.A. inspectors, were put in charge. Clemons returned
at 2:30-3:00 p.m. and resumed control.
8:14- a.m. — M.E.S.A. and Scotia employees inspected the mine for
hazardous conditions except for the 2 SEM section where ventilation
had not been restored.
6 p.m. — Thirteen men, including three M.E.S.A. inspectors, went
underground to repair the roof and restore ventilation. Since the roof
bolting machine needed to be repaired and moved to 2 SEM, the
team did not arrive near the entrance to 2 SEM until much later.
7-8 p.m. — Ben Taylor of M.E.S.A. returned to the mine after resting
and told Clemons about the locomotive and compressor in 2 SEM.
Clemons did not consider it important.
9 p.m. — William Clemons went home, Ben Taylor was left in charge
11:20 p.m. — Second Explosion occurred in 2 SEM. Rick Parker and
Ernest Collins, the two survivors, worked their way to belt telephone
and made the first call, reporting the explosion.
11:40 p.m. — News of explosion reached surface by way of the survi-
vors phone call. Taylor, fearing further danger, did not attempt a
rescue effort. Taylor called Clemons and relayed the information.
March 12, 1976
12:12 a.m. — The two Survivors reached good air and made 2nd
phone call. Survivors were told to wait for help, but they continued.
12:20 a.m. — Rescue men were sent into mine for survivors who were
found close to the mine entrance. Rescue teams were contacted.
12:59 a.m. — William Clemons returned to the mine and resumed con-
trol. Rescue attempts were made to reach the trapped miners but be-
cause of an air reversal, the attempts were abandoned.
6:55 a.m. — Two M.E.S.A. inspectors and miner representative were
lowered down an air shaft where the air was adequate.
9:45 a.m. — Three rescue teams were lowered down the shaft into
12 noon — Eleven bodies were found but not recovered.
1:02 p.m. — All rescue teams brought to surface.
March 19, 1976
2:10 p.m. — Mine ordered sealed.
March 24, 1976
Public Hearings conducted in Washington, D.C. by the Senate
Subcommittee on Labor of the Committee on Labor and Public Wel-
April 5-9, and April 27-80, 1976
Public hearings conducted in Whitesburg, Kentucky by the Mining
Enforcement and Safety Administration.
May 7, 1976
Joint Public Hearing conducted by the Senate Committee on Labor
and Public Welfare and House Committee on Education and Labor,
at Whitesburg, Kentucky.
May /.;. 1976
Joint Public Hearing conducted by the Senate Committee on Labor
and Public Welfare and Bouse Committee on Education and Labor
in Washington, D.C.
June Hk 1976
Joint Public Hearings conducted by The Senate Committee on
Labor and Public Welfare and House Committee on Education and
Labor in Washington, D.C.
June IS, 1976
A press conference was conducted by M.E.S.A. in Whitesburg,
Kentucky to announce tentative plans to reopen Scotia mine.
July 16, 1076
The reopening of the mine was begun.
Safety History of the Scotia Mine
The Scotia Coal Mine, near Oven Fork, Kentucky, whicb exploded
on March 9 and March 11, 1976, had a long and chronic history of coal
mine safety and health violations.
Mining Enforcement and Safety Administration (MESA) officials
have indicated that the Scotia mine was one of the most dangerous
coal mines in the United States. In addition to being the most gassy
mine in Eastern Kentucky, it had an abominable history of coal mine
safety and health violations. According to MESA inspection records,
since 1970, this mine was ordered closed 110 times — 39 times for immi-
nent danger conditions. During this same period, MESA also issued 855
notices of coal mine safety and health violations against the Scotia
Company, (see chart A)
According to a staff study prepared by the Senate Subcommittee on
Labor, during the period January 1974 and February 1976, the Scotia
mine was charged with 420 safety and health violations. The Senate
study indicated that at least 63 of the 420 violations were directly re-
lated to ventilation and methane conditions, (see chart B)
In addition to its general history of safety and health violations,
another critical aspect of Scotia's safety record was the complete lack
of an adequate safety education and training program. Testimony
presented by Scotia miners, Company officials and MESA profes-
sionals clearly indicated that Scotia's training and education program
was a "sham." According to the testimony, training in the use of self-
rescuers was sporadic, and fire and mine evacuation drills were nearly
In terms of the March 9 and March 11 explosions, the issues most
directly related to Scotia's safety record include (1) the history of
ventilation and methane problems, and (2) the lack of adequate
safety education and training programs.
I. ventilation and methane gas AT THE SCOTIA MINE
When high enough concentrations of methane gas (5 to 15 percent)
in an underground coal mine are associated with inadequate ventila-
tion and an ignition source, a violent coal mine explosion is very likely
to occur. In the opinion of all those associated with the Scotia mine
disaster, these three conditions apparently led to the explosions on
March 9 and March 1 1 .
In terms of methane gas, it is an accepted fact that the Scotia mine
was the most gassy mine in Eastern Kentucky. However, as compared
to other mines in other states, most notably in Virginia, the Scotia
mine was not considered as heavily gassy. The Scotia mine, according
to MESA, liberated an average of c 250,000 to 500,000 cubic feet of
methane gas in a 24-hour period. The aggregate amount of methane
liberated, however, is relatively unimportant if proper and adequate
ventilation exists to keep the methane concentrations below the ig-
Among the many legal provisions designed to guard against methane
explosions, MESA regulations require tests for methane at the start
of each shift and at each working place by qualified individuals. If
1.0 percent or more of methane is detected, electrical equipment must
not be taken into, started or operated at the working place. Exami-
nations and monitoring for methane are also required at 20 minute
intervals during the operation of electrical equipment. In addition,
the regulations require a pre-shift examination for accumulations of
methane within three hours preceding the beginning of any shift, and
before any miner in such a shift enters the active workings of a coal
mine. If 1.5 percent methane is detected at any time, all miners must
be withdrawn from the endangered area.
With respect to the Scotia mine the following facts are known:
• High concentrations of methane gas had previously been de-
tected by the MESA inspectors and Scotia company officials;
• Pre-shift examinations were not always conducted in accordance
with the law;
• Methane monitoring at the required 20 minute intervals was
not always complied with; and
• Federal ventilation requirements were frequently violated.
Methane concentrations. — In terms of high concentrations of methane
detected at the Scotia Mine, MESA inspection records indicate that
on at least seven separate occasions between January 1974 and Feb-
ruary 1976, MESA issued violation notices of high methane concen-
trations. On at least two separate occasions — November 18, 1974 and
January 7, 1975 — the Scotia mine was ordered closed because high
concentrations of methane were found by the MESA inspector. The
January 7, 1975 closure order indicated that an iminent danger con-
dition existed due to a combination of 1.2 percent methane and
inadequate ventilation, (see chart C)
In addition to the methane violations found by MESA, Charles
Fields — third-shift fire boss at the Scotia mine — testified before a
MESA investigation panel that on a number of occasions he detected
excessive concentrations of methane gas throughout the mine. During
the MESA hearings Fields was asked:
How often did you find more than say two percent of methane in work areas
or idle areas?
Fields. Well sometimes it will be a long time. And maybe you will find not
over two-tenths. And then sometimes you will get it where it will be nine percent
or three percent. (Emphasis added.)
At the same hearing, Fields also testified that he had been aware
of a methane gas feeder located hi the same section of the mine where
the two explosions occurred (2 Southca-t main). Fields said he n
ured at least a five percent methane concentration at the floor of the
mine where the feeder was located. According to Field-, the concentra-
tion could have been higher but his methane monitor measured only
up to a live percent level. Fields further testified that when he took
the same reading at a level somewhat above the mine iloor, "it showed
Besides Fields, other miners also testified to the existence of a
methane gas feeder in the 2 Southeast main section of the mine.
Pat Fate, a. shuttlecar operator, told the MESA panel that whenever
the mine iloor was wet in the 2 Southeast main section, methane gas
could be seen bubbling up through the water. According to Pate,
"it boiled just like boiling water on a hot plate." Others who testified
that they knew about the gas feeder included Arvil Cornett — Scotia
mine foreman, James Maggard — second shift maintenance foreman,
Fred Maggard — general superintendent of the Scotia mine, Harvey
Creech — Scotia stall foreman, and Ernest Collins — a Scotia miner.
Pre-shi/t mine exam l nations. — With respect to the pre-shift mine
examinations (fire bossing) required by the law, the MESA hearings
clearly established that the examinations w T ere not regularly made in
all working sections of the Scotia mine.
The MESA panel established that Scotia's only third-shift fire boss,
('In rles Fields, signed the fire boss book indicating that such examina-
tions had been conducted, even though many times he actually did
not make the inspections. According to the transcript of the MESA
Question. This (the fire boss book) begins on March 5, and those are the
records of the pre-shift examinations that were signed for by Mr. Fields prior
to the explosion. Those are your signatures at the bottom of this particular page?
You agree they are copies of the fire boss book?
Fields. Yes, sir.
Question. And you signed for the exams?
Question. But you did not make them (the examinations)?
During this exchange, .Robert Barrett, MESA administrator, also
established the fact that Fields very infrequently fire bossed the 2
Southeast main section of the mine where the explosions occurred.
According to the transcript:
Barrett. Were you in 2 Southeast Mains after the (continuous) miner pulled
out of that section of the mine where the explosions occurred?
Barrltt. How often did you get up there?
Fields. Well, not very often.
Barrett. There were approximately six weeks between . . . the time the
equipment was pulled out of the Mains and moved into 2 left . . . How many
times would you say during that five or six week period were you up the mains?
Fields. Really I was up in there I would say twice.
Fields al-o testified that he had not fire bossed the 2 Southeast main
section of the mine immediately prior to the shift in which the March
9th explosion occurred.
The Fields testimony indicated that he and Arvil Cornett, Scotia
mine foreman, had an arrangement whereby they shared the fire
bossing duties. Cornett's testimony confirmed this arrangement but
it also confirmed that no one fire bossed the 2 Southeast main section
of the mine immediately prior to the shift in which the first explosion
The Fields-Cornett testimony demonstrated that there was no set
pattern for dividing up the fire bossing responsibilities between them.
This led to apparent confusion and a failure on occasion to cover the
The 20-minute methane monitoring rule. — There is evidence in the
record to suggest that the 20-minute methane monitoring rule was
repeatedly violated at the Scotia mine. On at least one occasion
(July 8, 1975) Scotia was cited by a MESA inspector for failure to test
for methane at the required 20-minute intervals. Furthermore,
testimony taken from Scotia miners indicated that the 20-minute rule
was seldom followed. According to Carlos Smith, a Scotia continuous
miner operator, this requirement was repeatedly violated. According
to the MESA hearing transcript:
Question. Are you aware of a requirement that gas has to be checked periodic-
Smith. Yes, sir.
Question. Do you know how often that is?
Smith. Every twenty minutes, I believe.
Question. Would you say that gas was being tested for every twenty minutes?
Smith. No, sir.
Smith also testified that while he was not qualified to test for
methane gas, he nonetheless regularly made such tests at the miner
which he operated. Additionally he stated that while the section fore-
man was supposed to test for methane at the miner, he, Smith, was
"not sure , ' how often the tests were made. Smith did state that the
tests were very seldom taken while he was operating his equipment.
The safety history of the Scotia mine demonstrates serious and
repeated ventilation violations, problems and illegal practices. In the
two year period preceding the disaster, the Scotia mine had been cited
63 separate times by MESA for ventilation violations. Of this total,
26 violations were attributed to not enough air reaching the working
face of the mine, and 18 violations were for failure to follow the MESA
approved ventilation plan. Other ventilation violations included line
brattices being out of position, inoperative methane monitors, high
methane concentrations, permanent brattices unconstructed, lost coal
and coal dust, and fans and other equipment not properly equipped
In addition to the history of MESA-cited ventilation violations,
there is evidence indicating that MESA inspectors were intentionally
misled as to the ventilation in the mine, and that air was regularly
diverted from one section of the mine to another during MESA
At the Joint House and Senate committee hearings, Ronald Ledford,
a former Scotia miner, testified that he personally witnessed air being
diverted from one section of the mine to another in anticipation of a
MESA inspection. Under questioning by Chairman Carl Perkins,
Ledford said that he had accompanied James Bentley, assistant mine
foreman for ventilation at Scotia, on three occasions when air was
diverted. According to Ledford, -
We would go to the (air) regulators, and whatever section he (the MESA
inspector) was coming on, he (Bentley) would kind of slide the doers closed o\<r
another section, and they would put more air into another section — the Bection
that the inspector would conn- in— for more air, and (then) they would shut it
According to the hearing transcript:
i\s. Ybu mean they would switch the air around?
Li.di ORD. Ui^ht.
Perkins. How often did they do this?
LedFORD. I went with him (Bentley) three times when he done it.
Perkins. Over what period of time did this take place?
Ledpord. Back in about seven or eight months.
A number of other Scotia miners gave testimony which essentially
substantiated Ledford's assertions. Furthermore, they also testified
that they personally were involved in instances where MESA in-
spectors were intentionally misled as to ventilation and other safety
conditions in the mine. Taken as a whole, the testimony of Gary
Smith — a utility man, Carlos Smith — a continuous miner operator,
Merle Rhodes — assistant second-shift foreman, Glen Sturgill — former
Scotia miner, Everett Boggs — former Scotia miner, and Pat Pate —
shuttle car operator, presented a ringing indictment of the manner in
which the air in the mine was diverted, and inspectors misled.
ii. scotia's safety education and training record
Robert Barrett, MESA Administrator, testified before the joint
House and Senate Committee that MESA's investigation "clearly
revealed that the Company's training program at Scotia was a sham."
Nothing more tragically demonstrates Scotia's sham program than the
fact that six of the miners who died on March 9th probably could
have saved themselves had they received proper training in fire drill
techniques and evacuation procedures. These six men did not die as a
result of the initial explosion, but suffocated to death when their
self-rescuers became inoperative. Following the initial explosion, the
six apparently barricaded themselves in the 2 Left panel, off 2 South-
east main and sat there until they died
MESA and state officials reportedly said that the six miners who
suffocated might have survived had they simply tried to walk out of the
mine following the explosion. According to Harreld Kirkpatrick,
Commissioner of the Kentucky Department of Mines and Minerals,
"We feel that the self-rescuers, with what we know now, they (the
six miners) could have walked out 3% miles in an hour" (the self-
resouers were good for about an hour). In testimony before the Joint
House-Senate Committee, Monroe West, Subdistnct manager of
MESA's Norton, Ky. office, said, "Sir, if they (the six miners) at-
tempted to come out of there (the mine) there is a good possibility
that they could have made it." MESA Administrator Robert Barrett,
at a congressional briefing on March 15, 1976, also expressed the
opinion that the six men probably could have saved themselves by
\\ alking out of the mine.
However tragic this example of six dead men might appear, their
failure to act should not be surprising in light of Scotia's record on
safety education, particularly with respect to lire and evacuation
drills. Testimony taken from Scotia miners and officials clearly
established the lack of an overall, adequate safety education program
at the mine.
With respect to fire drills, escapeway procedures, and disaster-type
situations, the hearing record is replete with evidence that most of the
miners had never received proper training and instruction. Fred
Maggard, the General Manager of the Scotia mine, told the MESA
investigation panel that he did not know when the last fire drill had
been conducted. Kis testimony indicated that he knew very little
with respect to anything related to training and education. Maggard
said that all safety training and education activities were the re-
sponsibility of the Company's safety personnel.
Charles Kirk — the only safety man employed by the Scotia coal
company — testified that to the best of his knowledge not one lire or
evacuation drill had been conducted at the mine during his tenure as
the Company's safety inspector, approximately 3% year-, lie further
testified that he was the only Company safety inspector and was
responsible for all three of Scotia's mines including Scotia No. 1
where the disaster occurred. Kirk stated that he had not been in the
Scotia Xo. 1 mine during the 3-month period prior to the disaster.
Richard Combs, general Scotia mine foreman, told the MESA panel
that while he was aware that evacuation drills were required, lie was
not familiar with the federal regulations as such.
David McKnight, President of the Scotia Employee- Association,
in re.-ponse to questioning from Chairman Car; Perkins told the Joint
House-Senate investigation committee that "I have never known of a
tire drill" and "as far as escapeways, sir, nothing about escapeways. I
could go into those mines and never get out myself." Others who
testified concerning the lack of safety training and fire and evacuation
drills included Roger McKnight. Jasper Cornett, Carlos Smith, Glen
Sturgill, and Everett Boggs.
MESA's Enforcement Efforts at the Scotia Mixe
In terms of effectiveness MESA's enforcement efforts relative to the
Scotia coal mine leave- much to be desired. Nothing more clearly
demonstrates this ineffectiveness than the tragic fact that on March 9
and March 11, 1976, the Scotia mine exploded killing 26 men. MESA's
enforcement shortcomings with respect to this mine have been inad-
vertently admitted in the Agency. According to MESA Administrator,
Robert Barrett, "prior to the explosions, federal inspectors had spent
more than 1,000 man-days inspecting the Scotia mine, issuing 855
notices of violations and 110 closure orders." Other MESA officials
have testified that the Scotia nunc was the most inspected mine in
Eastern Kentucky. The question thus arises why, after all the MESA
inspection activity, notices and closure orders, did the Scotia mine
continue to operate a- an unsafe and dangerous mine?
The answer, is that the Scotia Coal Company was essentially per-
mitted to ignore the law. We are convinced that MESA failed to
adequately u>e it< authority to properly enforce the Coal Mine Health
and Safety Act at the Scotia mine.
Our investigation of MESA's enforcement efforts at the Scotia mine
has raised a number of serious policy questions including:
1. MESA's policy governing the concept of imminent danger
under Section 104(a) of the Coal Mine Health and Safety Act;
2. MESA's policy governing mine closure orders particularly
with respect to Section 104(c) of the Coal Mine Health and Safety-
Act (unwarrantable failure to comply);
^ 3. MESA's policy governing its Section 109(b) authority under
the Coal Mine Health and Safety Act (criminal penaltie
4. MESA's policy governing the assessment and collection of
monetary penalties for coal mine health and safety violations;
5. MESA's policy governing coal mine safety and health inspec-
tions and procedures.
i. mesa's policy governing the concept of imminent danger :
- tion 104(a) of the Coal Mine Health and Safety Act tates:
Jf. upon any inspection of a coal mine, an authorized representative of the
Secretary i\nd< that an imminent danger exists, such representative shall determine
the area throughout which such danger exists, and thereupon shall issue forthwith
an order requiring the operator of the mine or his agent to cause immediate
persons (except certain selected individuals) to be withdrawn from, and to be
prohibited from entering, such area until an authorized representative of the
Secretary determines that such imminent danger no longer exists.
The Act defines imminent danger as "the existence of any condition
or practice in a coal mine which could reasonably be expected to cause
death or serious physical harm before such condition or practice can
Throughout this investigation, MESA officials have been repeatedly
asked the question, "Why — given the mine's history of ventilation
violations and methane concentrations — was the Scotia mine permitted
to operate?" The specific policy question which lias arisen is whether —
based upon a mine's prior history of coal mine health and safety
violations — the operation of a mine, could of itself be considered as
imminently dangerous and therefore ordered closed until chronic
safety and health problems are permanently abated?
MESA officials have testified that in their view the Agency does
not have the authority, under the Act, to use Section 104(a) in the
above manner. However, they have also testified that MESA has not
sought to test the concept hi the federal cowls. According to MESA Ad-
ministrator Robert Barrett, "A question has been asked as to why
MESA failed to close the Scotia mine permanently on the theory
that its rate of methane liberation constitutes all by itself an im-
minent danger . . . The answer to that question is that, in our
view, there is no authority under the Federal Coal Mine Health and
Safety Act of 1969 to take that kind of action as long as the mine is
properly ventilated." (emphasis added) Robert Long, MESA's
Associate Solicitor, summcrized MESA's policy in this respect when
he stated to Mr. Perkins, "Each violation gets assessed separately
. . . That's the way this law is written . . . Once that violation is
abated, that notice or order, as the case may be, has to be lifted . . .
If you want to look at the record and say there are sixteen notices of
violation or sixteen orders and those sixteen comprise in themselves
imminent danger, I don't think that's what this law provides as it is
written today." According to the hearing (June 16, 1976) transcript:
Perkins. A situation like that exists and you come here complaining that no
imminent danger exists, it i- beyond my comprehension.
Loxg. I did not claim no imminent danger existed. There were quite a few
imminent danger orders on this mine. What I ■■■aid was that a sum total of those
orders docs not, in and of itself, compromise imminent danger. (Empha>is added.)
Perkins. Have you ever tested in the courts whether a string of violations
that you talk about constituted the danger?
Long. No, sir.
Perkins. Why haven't you?
Long. Because / don't believe that that is what this law provides and / don't
think the Justice Department agrees either. (Emphasis added.)
MESA officials have further testified that they need additional mine
closure authority to deal with mines like Scotia. While this may be r
it is our position that MESA has not fully tested the authority that
it already has under Section 104(a) of the Act. It is not enough to
simply state that "in our view" or "I don't believe" that the Act
contains the necessary authority to apply the imminent danger
closure provision to a mine with chronic safety and health violations.
The Scotia mine is a primary example of where MESA should have
tested, in the courts, its 104(a) authority. Only after testing such
authority, and receiving an adverse definitive ruling, do we believe
that MESA should come to the Congress and ask for additional
authority. The Interior Department has had six years to address this
question in the courts and it has thus far failed to do so. We believe
that this is a serious policy shortcoming on the part of the
Of all the enforcement tools contained in the Coal Mine Health and
Safety Act of 1969, perhaps the most potent are those relating to the
Federal Government's authority to effectively close a mine by issuing
orders for the withdrawal of the miners. The issuance of such orders can
severely interrupt coal production and thereby impact directly on the
business of a coal company. This is compared to federal fines for health
and safety violations which, for the most part, are considered by the
companies as an integral part of doing business. As will be discussed
later in this report, the fines levied by MESA against Scotia were at
best a nuisance and had no lasting impact on the Company's safety
and health policies. If properly used, however, closure orders can have
a substantial effect on the ability of a company to conduct its business
and therefore constitutes an impressive tool to effectively enforce mine
health and safety.
Unfortunately for the 26 Scotia miners who died in the March 9 and
March 11 explosions, MESA failed to adequately use its mine closure
authority to effectively impress upon Scotia's management the sevcrity
of the mine's safety and health problems. MESA's record in this
respect leaves much to be desireti, particularly in terms of the inade-
quate use of its Section 104(c) authority, which is perhaps the most
effective mine closure tool for controlling the day to day operations of a
mine like Scotia. As will be discussed more full}" below, Section 104(c)
essentially provides for the closure of a mine where there are unwar-
rantable failures on the part of an operator to comply with the federal
health and safety standards.
MESA's Mine Closure Authority .—The Coal Mine Health and
Safety Act of 1969, provides MESA with the authority, under certain
circumstances, to effectively close coal mines by issuing orders for the
withdrawal of miners. The act provides for the following types of mine
Imminent Banger. — Section 104(a) provides thai if an author-
ized representative of the Secretary of the Interior (MESA) finds
that an imminent danger exists in a coal mine he shall forthwith
issue an order requiring all persons to be withdrawn immediately
from the mine, or affected mine area, until such time that the
representative determines that the imminent danger no longer
Failure to Abate. — Section 104(b) provides that whereupon any
inspection of a coal mine by an authorized representative of the
Secretary finds that there has been a violation of a federal health
or safety standard which has not created an imminent danger, the
representative shall issue a notice of violation fixing a reasonable
time period for its abatement. If the violation has not been abated
in the specified time period or possible extension thereof, then the
representative shall issue a withdrawal order with respect to those
miners affected by the violation. The withdrawal order shall
remain effective until such time that it is determined that the
violation has been abated.
Unwarrantable Failure to Comply. — Section 104(c) provides for
two types of withdrawal orders. Under Section 104(c)(1) if an
authorized representative of the Secretar}- finds a violation of a
health or safety standard which does not pose an imminent danger,
but which could cause a mine safety or health hazard, and if he
finds that the violation resulted from the unwarrantable failure of
the mine operator to comply with the standards, then the inspec-
tor shall issue a notice to this effect. If during the same inspection,
or any subsequent inspection within 90 days, the inspector finds
another violation which resulted from the unwarrantable failure
to comply, he is required to issue a withdrawal order. The order
remains in effect until such time as the violation is abated.
Section 104(c)(2) provides that once a withdrawal order under
104(c)(1) has been issued, additional such orders shall be issued
if, upon any subsequent inspection, violations are found similar
to those for which the initial 104(c)(1) order was issued. This
order shall remain in effect until such time as an inspection
determines the absence of any such similar violations. Following
an inspection which determines that no similar violations exist,
the provisions of 104(c)(1) are again applicable. According to the
legislative history of the Coal Mine Health and Safety Act, Con-
5S defined "unwarrantable failure of the operator to comply''
to mean "the failure of an operator to abate a violation because
of a lack of due diligence, or because of indifference or lack of
reasonable care, on the operator's part."
Mine Control Following an Accident. — Section 103(f) provides
that a federal inspector ma}' i- I orders following a
mine accident to insure tie of any person in the mine.
Except for the imminent danger closure authority, which, under
curri A policy, is applicable only in limited circumstances — the
unwarrantable failure pro vision is the most effective closure tool in
controlling the day to day operations of a mine like Scotia, with a
demonstrated history of chronic mine safety and health violations. A
close reading of the legislative history of the Coal Mine Health and
Safety Act indicates that Congress designed Section 104(c) precisely
for mines like Scotia whose operators repeatedly demonstrated a lack
of "due diligence," "indifference" and "lack of reasonable care." Having
once determined the existence of such an attitude — which the record
indicates was rampant at Scotia — MESA could and should have used
its Section 104(c) closure authority to the utmost. The fact that the
Scotia mine was essentially permitted to continue to operate in an
unsafe and dangerous manner is an indictment of MESA's effectiveness
with respect to the use of its mine closure authority.
MESA's Mine Closure Record at the Scotia Mine. — According to
MESA records, during the period May 13, 1970 to March 9, 1976,
855 notices of safety and health violations were issued to Scotia. In
addition, the Scotia mine was ordered closed 110 times during this
period. At the very least, therefore, Scotia was found to have violated
the Coal Mine Health and Safety Act some 965 times prior to the
March 1976 disaster. As already determined elsewhere in this report,
Scotia repeatedly deceived MESA inspectors with respect to safety
and health problems in the mine. Thus, it can be assumed that there
were many more instances of violations that were never uncovered
The number of closure orders issued by MESA against Scotia are
somewhat deceiving since in almost every case the closure order was
lifted the same day it was issued. Given Scotia's continued "MESA
be damned" attitude, it must be assumed that MESA's closure orders
had a minimal effect on proper mine safety and health at the Scotia
Even when dealing with the Scotia numbers, MESA's mine closure
record is inadequate. Of the 110 closure orders issued, 39 were for
imminent danger, 23 were for failure to abate in time, 46 were for
unwarrantable failure to comply, and 2 were for accidents. In terms
of ventilation and methane conditions at the Scotia mine, MESA
issued a total of 149 notices of violations but only 23 closure orders;
3 for imminent danger, 2 for failure to abate, and 18 for unwarrantable
failure to comply. In almost every case the ventilation closure order
was terminated by MESA the same day it was issued.
Given Scotia's history, it is inconceivable that the mine was only
ordered closed 23 times for repeated ventilation violations, particularly
in view of MESA's authority to close the mine for unwarrantable
failure to comply with the federal ventilation standards. During the
15-month period immediately prior to the March 9 disaster, Scotia was
found to have violated the ventilation standards some 33 separate
times, but only 4 Section 104(c) closure orders were issued, all of which
were terminated by MESA the same day they were issued. As far as
we are concerned this demonstrates an unwarrantable failure on the
part of MESA to use its authorit} r to adequately enforce the law.
To illustrate MESA's casual policy governing closure orders at the
Scotia mine, the following case history is instructive. We have selected
the 15- month period prior to the disaster to demonstrate MESA's
enforcement activities with respect to Part 75.301 of MESA's Ventila-
tion Standards: "Not enough airjre aching the face of the mine".
On January 27, 1975 MESA issued a 104(c)(2) closure order for
a 75.. SOI violation; the order was lifted that same day;
On January 30, 1975 MESA issued a notice for a 75.301 vio-
lation which was terminated the same day;
On February 25, 1975 MESA issued a notice for a 75.301
violation which was terminated the same day;
On March 13, 1975 MESA issued a notice for a 75.301 violation
which was terminated the same day;
On March 19, 1975 MESA issued a 104(c)(2) closure order for a
75.301 violation; the order was terminated the same day;
On April 24, 1975 MESA issued a 104(c)(2) closure order
for a 75.301 violation; the order was terminated the same day;
On May 27, 1975 MESA issued a notice for a 75.301 violation
which was terminated the same day;
On July 10, 1975 MESA issued a notice for a 75.301 violation
which was terminated the same day;
On July 28, 1975 MESA issued a notice for a 75.301 violation
which was terminated the same day;
On August 25, 1975 MESA issued a notice for a 75.301 violation
which was terminated on August 27, 1975;
On September 17, 1975 MESA issued a notice for a 75.301 vio-
lation which was terminated the same day;
On September 29, 1975 MESA issued a notice for a 75.301
violation which was terminated on the same day;
On January 13, 1976 MESA issued a notice for a 75.301 viola-
tion which was terminated the same day;
On January 20, 1976 MESA issued a notice for a 75.301 viola-
tion which was terminated the same day;
On January 29, 1976 MESA issued a notice for a 75.301 viola-
tion which was terminated the same day;
On March 8, 1976, the day before the mine exploded, MESA
issued two notices for two 75.301 violations, w r hich were terminated
that same day.
This 15-month record of MESA enforcement efforts with respect
to Part 75.301 clearly indicated that there was something chronically
wrong with Scotia's ventilation system. On sixteen different occasions
MESA found that there .was insufficient air reaching the working
faces of the mine, yet only three 104(c) closure orders were issued for
unwarrantable failure to comply with Part 75.301. In all three cases
the closure order was terminated by MESA the same day it was issued.
The question confronting MESA is why did the agency not use its
closure authority, particularly its Section 104(c) powers, to effectively
interrupt the production of coal at the Scotia mine until such time
that the Company made fundamental changes in its safety and health
attitudes and policies Thus far, MESA has not produced an adequate
and acceptable answer to this question. What is known, however, is
that MESA's mine closure policy at the Scotia mine was not sufficient
enough to impress upon the Company the full measure and force of
the law. The Scotia management apparently found that it was more
profitable to operate the mine in violation of the law than to make
the changes necessary for compliance.
in. mesa's policy governing criminal sanctions
In addition to its mine closure authority, MESA has the power to
seek criminal sanctions against operators who knowingly and willfully
violate the Coal Mine Health and Safety Act. According to Section
109(b) criminal charges can be brought against "any operator who
willfully violates a mandatory health or safety standard, or knowingly
violates or fails to comply with any order issued under Section 104 . . ."
Throughout its entire history of enforcement at the Scotia mine,
MESA never once sought to bring criminal actions against the Com-
pany. We believe that Scotia's record of violations, spanning a six year
period, constitutes, at the very least, knowing and willful violations
of mandatory health and safety standards. Whether a court would
agree is not now in issue. The simple fact is that MESA never sought
to bring criminal charges against the Scotia company whose record,
on its face, should have been enough to spur MESA to file such
Why did MESA fail to use its criminal sanction authority with
respect to the Scotia mine? Part of the answer has to do with MESA's
overall policy governing Section 109 (b) and (c). According to Senator
Harrison Williams, the following constitutes MESA's overall criminal
sanctions record from mid-1974 to date:
• 342 requests from the field to investigate possible criminal
• 288 cases have been assigned for criminal investigation;
• 117 criminal investigations have been completed;
• 38 cases were recommended from the field for criminal or civil
• 17 cases have been forwarded to the Interior Department
Solicitor's office for action. Of the 17 cases forwarded to Interior's
Solicitor, 5 recommended criminal action.
This rather dull record was further substantiated when assistant
MESA administrator John Crawford told Senator Williams "To
answer your question, we have looked at three hundred some cases . . .
Again, I am not a lawyer, but somewhere in there we have only
arrived at a very few out of those that apparently are strong enough
to cany through for prosecution."
Thus far, MESA has not adequately defined the criteria used for
deciding when to pursue Section 109(b) or (c) actions, but the law
appears to be clear. The tests, according to the law, are willfully
violating a mandatory standard or knowingly violating or failing to
comply with an order, particularly a Section 104 order.
In terms of the Scotia mine, there is strong evidence to suggest that
local MESA officials were aware of willful violations and knowing
failures to comply with orders. This evidence also suggests that
because of MESA's cumbersome investigative procedures, very little
was done to pursue criminal sanctions against Scotia. In an exchange
between Senator Williams, Chairman Perkins, and Lawrence Phillips,
MESA's District Manager of the Pikeville Kentucky Office — with
jurisdiction over the Scotia mine — it was brought out that criminal
sanctions against the Scotia mine had been recommended. According
to the hearing transcript.
Williams. Have you ever considered recommending these severe (criminal)
penalties if you couldn't get to the boitom of unsafe conditions in that (Scotia.'
77-243— 7G 4
PHILLIPS. Yes, on specific instances I have. We review every "C" (Section 104
(c)) type action in the district and every order. The inspector who wrote the action
along with his supervisor, first make the determination whether or not they think
it is willful. It passefl on to a man in the district who we call a special investigator
who baa BOme training along those lines. If he considers it willful, it comes to me
. 1 read it. If I also agree with him, I forward it to Mr. Crawford's office.
Perkins (later in the dialogue). The willful penalty statute that Senator
Williams was referring to is in there, and it was not applied?
PHILLIPS. I can't say it wasn't applied. We had recommended in certain in-
stances for willful provisions to apply.
Pbbkins. To this particular mine?
Phillips. Yes Sir.
Pi kkins. What happened? Why didn't it stop?
Phillips. These are presently being investigated.
Pbbkins (later in the dialogue). Getting back to the willful penalty section,
Mr. Phillips, you stated that some recommendations were made. Who made the
recommendations, and when were they made? Before or after the disaster?
Phillips. I made the recommendations and I made them before (the disaster).
Perkins. How long before?
Phillips. I made one two weeks after I got there. September 17, 1975.
Pi. kkins. You never heard any outcome from that recommendation? Never got
any reply back?
Phillips. It is being investigated. None other than that.
Perkins. None other than it was being investigated? Who was supposed to
make that investigation after you made your recommendation?
Phillips. Mr. Crawford has on his staff the people who evaluate this, and I
really don't know what all is involved, but then it comes back to the special
investigator who is in my district, to run all the facts in the case.
Perkins. Did it ever come back to the special investigator in your district to
run up the recommendations you had made in September of last year?
Phillips. Yes sir.
Plrkins. What was his decision?
Phillips. He has not completed the investigation at this time.
Perkins. He has not completed the investigation at this time?
Perkins. And you made the recommendation last September, is that right?
Perkins. Of willful violations?
Phillips. Yes sir.
Perkins, (later in dialogue). I want to know what in your opinion constitutes
Phillips. That is a pretty tough question. To me it would almost be akin to
Perkins. Do you feel that there was wanton neglect there at that (Scotia) mine
and was that the reason that you made those recommendations?
Phillips. In certain instances I do, yes.
From this: record, it is rather obvious that the MESA officials
directly responsible for the Scotia mine believed that the mine was
being operated in a manner which willfully violated MESA's stand-
ards, yet no criminal action was taken against the Company. From
September 1975 until now all that has been done was to investigate.
The recommendation for willful violation sanctions was made five
months prior to the disaster but, as far as Scotia was concerned, no
action was taken. At the very least MESA should be called to task for
a bureaucratic procedure which slows the criminal sanction process to
something less than a snail's pace. At worst, MESA's record on crimi-
nal sanctions particularly in terms of the Scotia mine, indicates an
institutional policy designed to thwart the intent of the law. "Whatever
the case, MESA absolutely foiled to use one of its most potent enforce-
ment weapons on a mine which amply demonstrated a willful and
"wanton neglect" of federal coal mine health and safety standard.-,.
iv. mesa's policy governing the assessment and collection of
In addition to its mine closure and criminal sanction authority,.
MESA has the power to assess and collect monetary penalties for
violations of coal mine health and safety standards. While this author-
ity is not as potent as closing a mine or bringing criminal charges, it
can, if properly used, serve as an effective enforcement tool.
With respect to the Scotia mine, it has been concluded that MESA's
use of its monetary penalty powers was totally ineffective in bringing
about compliance with the federal standards. A review of the record
clearly indicates that the penalty amounts assessed by MESA against
Scotia for violations were low to begin with, and the fines actually
collected were substantially lower. Given Scotia's continued and
repeated violations, it can be assumed that the Company viewed the
MESA fines merely as nuisances, with little or no lasting impact on
the Company's safety and health attitudes or policies. Scotia ap-
parently found it cheaper to pay the fines than to comply with the
law. MESA's efforts in this regard must be regarded as nothing more
than a "slap on the hand."
Section 109(a)(1) of the Coal Mine Health and Safety Act provides
that an operator of a coal mine in which a violation of a mandatory
standard occurs shall be assessed a civil penalty of up to $10,000 per
violation. According to the Act, "In determining the amount of the
penalty, the Secretary of Interior shall consider the operator's history
of previous violations, the appropriateness of such penalty to the
size of the business of the operator charged, whether the operator was
negligent, the effect on the operator's ability to continue in business,
the gravity of the violation, and the demonstrated good faith of the
operator charged in attempting to achieve rapid compliance after
notification of a violation."
Of all the criteria spelled out for determining the amount of the
penalty, Congress intended the negligence factor to be pre-eminent.
According to the House-Senate Conference Report which accompanied
the Act, "The Secretary shall apply the more appropriate negligence
test in determining the amount of the penalty, recognizing that the
operator has a high degree of care to insure the health and safety of
persons in the mine."
MESA monetary penalty record j or the Scotia Mine
According to MESA, about $78,000 in fines have been collected from
Scotia during the period from May 1970 to March 1976. While on its
face this figure might appear impressive, it represents only a fraction
of the total fines assessed against the Company. In many cases, the
amount actually collected from Scotia was as much as 50% less than
the amount initially assessed.
A more appropriate way of analyzing MESA's monetary penalty
record is to examine the specific Scotia figures. For example, the
highest penalty assessed against Scotia for a ventilation violation
during the period January 1974 to June 1975 (the latest figures
available) was $582, assessed on 4/18/75 for a Part 75.301 violation,
"not enough air reaching the working face of the mine." The amount
actually collected for this violation was $291, or reduettai. Ai
a matter of fact, this $291 was the largest amount ever paid by
ia for a ventilation violation during the January L974-June
A- for other types of violations, the following represents the highest
penalties d and collected from Scotia during the 1**74 -197/5
• Electrical equipment: highest assessed penalty 8(364; highest
collected penalty $190; a reduction of almost 50 percei
• CombustiDle Materials and Rock Dusting: highest asse
penalty $1746; highest collected penalty $873; a reduction of 50
• Fire Protection: highest assessed penalty $436; highest collected
penalty $275; a reduction of almost 40 percent;
• Dust Standards: highest assessed penalty $218; highest collected
penalty $102; a reduction of more than 50 percent;
• Trailing Cables and Grounding: highest assessed penalty $582;
highest collected penalty $291; a reduction of 50 percent;
• Roof Support: highest assessed penalty $1104; highest collected
penalty $582; a reduction of 50 percent;
• Surface Work Areas: highest assessed penalty $436; highest
collected penalty $400; a reduction of less than 10 percent;
• Maps, Hoistings and Mantrips: highest assessed penalty $73;
highest collected penalty $50; a reduction of some 30 percent;
• Miscellaneous: highest assessed penalty $220; highest collected
penalty $220; no reduction.
To further illustrate MESA's low assessment and even lower
collection rates, the following is instructive with respect to ventilation
violations at the Scotia mine:
• Jan. -Mar., 1974: average assessed penalty $296; average collected
• April-June, 1974: average assessed penalty $288; average col-
lected penalty $167;
• July-Sept., 1974: average assessed penalty $159; average col-
lected penalty $140;
• Oct.-Dec, 1974: average assessed penalty $140; average collected
• Jan.-Mar., 1975: average assessed penalty $222; average collected
• April-June, 1975: Average assessed penalty $134; average col-
lected penalty $98.
(Notb. — These figures were compiled by the Senate Subcommittee on
Labor with the assistance of the General Accounting Office.)
Another factor inhibiting effective enforcement at Scotia was the
time lag from the date of a violation to the date of assessment, and
from the date of violation to the date of collection. For ventilation
violations at the Scotia mine, during the period January 1974-
February 1976, this lag averaged IDS days from the violation to the
te, and 270 days from the violation to the collection date.
In other words, for ventilation violations at the Scotia mine it took an
average of almost nine months from the time a violation was found
until the time the assessed penalty — reduced in some cases by as much
as 50 percent — was actually collected.
It should be noted here that over the course of its enforcement
efforts at the Scotia mine MESA has, on three separate occasions,
assessed the maximum civil penalty of $10,000. Two of the three
cases involved fatalities and the other involved serious physical
injuries. All three accidents occurred prior to the March 9 and
March 11, 1976 explosions. In one of the fatality cases, Scotia settled
out of court and paid a fine of $5,500. The other two $10,000 penalty
assessment cases are pending.
MESA's attitude towards penalties
In reviewing MESA's record on monetary penalties against the
Scotia mine, it appears that, at the very least, MESA did not apply
the criteria spelled out in the law for determining penalty amounts.
While it is true that an affected operator has the right to appeal an
;sed penalty to the Secretary of the Interior and ultimately to
the courts, it is equally true that the law places upon the Secretary
the responsibility^ for applying certain criteria for determining the
amount of the penalty.
As indicated above, the law instructs the Secretary to make a
determination based upon:
• the operator's previous history of violations;
• the size of the operator's business;
• the operator's negligence;
« the ability of the operator to remain in business;
• the gravity of the violation; and
• the demonstrated good faith of the operator to comply.
When compared to Scotia's history of violations and MESA's
monetary penalty response to those violations, it is clear that MESA
failed to apply these criteria. One would think that as Scotia built
its record of repeated violations, MESA would have increased the
fines for each succeeding violation. However, the available MESA
records clearly indicate the reverse. The numbers available from
January 1974 to June 1975, clearly indicate a trend towards reduced
average penalty assessments and collections.
In other words, rather than increasing the penalties as the viola-
tions mounted — as the law implicitly instructs — MESA actually
reduced or, at best, kept constant the size of the penalties during
the period 1974-1975.
During the Joint House-Senate hearings, MESA and Interior
Department officials were repeatedly questioned on MESA's penalty
assessment and collection policies and efforts. These officials gave
the panel no sound reason why the initial assessments for violations
at the Scotia mine were low, given the mine's history of repeated
violations. As a matter of fact, MESA Administrator Robert Barrett
admitted to Representative Perkins that "they (the assessments) are
too low ... I will agree with that one hundred percent." As for the
rather substantial reductions from the amount initially assessed to
that ultimately collected, Robert Long, Associate Solicitor for MESA,
sought to explain that the reductions, in general, resulted from the
appeal process available under the law. However, Mr. Long did not
explain the apparent pattern of reductions which, for the Scotia
mine, approximate 50 percent in many eases. In terms of the long time
lag from the finding of a violation to assessment and collection, Mr.
Long also cited the various procedures involved in the appeal process.
From our review of MESA's policy governing monetary penalties,
it is apparent that this policy failed and failed miserably as an effective
enforcement tool with respect to the Scotia mine. In spite of all
MESA's rationalizations and explanation-, it i- clear that the intent,
if not the letter, of the law was insufficiently applied. Initial as
ments for violations at the Scotia mine were low and were not com-
mensurate with the mine'- history of violations. Also, on the average,
there appears to be a consistent pattern of an approximate 50 percent
reduction in the amount collected as compared to the amount initially
3sed. The time lag from violation to assessment and collection
provided Scotia with little incentive to comply with the law. In addi-
tion, the only instances where MESA even attempted to bring the full
civil penalty weight of the law to bear on Scotia, by assessing the
maximum allowable penalty, involved two cases of fatalities and one
ease of serious physical injuries. Thus far, MESA has only collected a
penalty in one of those fatality cases, the collected amount being some
45 percent less than the $10,000 initially assessed.
From the facts at hand, it appears" that MESA's attitude with
respect to monetary penalties at the Scotia mine consisted of:
1. Only applying the maximum penalty in cases where deaths
or serious physical injuries had already occurred;
2. In other cases only making those assessments which the
agency thought it could collect;
3. In many, if not most, cases settling for something approx-
imating 50 percent in actual dollars collected;
4. Being apparently content with a process which permits a
long lag time from the date of violation to the date of assessment
v. mesa's policy governing health and safety inspections:
As previously stated in this report, MESA failed to adequately
apply its mine closure, criminal sanctions, and monetary penalty
authority to effectively enforce the Coal Mine Health and Safety Act
at the Scotia mine. In addition, the Scotia case demonstrates serious
shortcomings in MESA's inspection efforts and activities.
Even though the Scotia mine was the most inspected coal mine in
Eastern Kentucky, MESA's inspection efforts at the mine had little
impact on correcting Scotia's chronic health and safety problems.
After some 1,000 man-days of inspection activity, the Scotia mine
continued to repeatedly violate established federal health and safety
Robert Barrett, MESA's Administrator, has testified to the effect
that MESA's investigation into the Scotia disaster has, among other
things, uncovered some serious shortcomings in MESA's inspection
procedures and policies. According to Barrett, "We have learned
many things from the nine days of hearings (conducted by MESA)
about explosions, the Scotia and Blue Diamond Coal Companies, and
about the effectiveness and shortcomings of MESA." (emphasis added).
In an attempt to correct some of these "shortcomings", Barrett
told the Joint House-Senate panel that, among other actions, MESA
was moving immediately to :
• conduct frequenl "blitz" insp
• conduct more detailed and lews of ventilation and
miner training plans
• promulgate mandatory education and training standards;
• implement a "mine" profile rating system";
• expand an on-going accident prevention program;
• computerize and speed-up the assessments of civil penalties;
• "beef-up" training of federal inspectors in areas of mine rescue
and recovery work ; and
• draft new standards requiring better emergency survival equip-
ment and materials.
While the items of this list point out some of MESA's shortcomings
and while they are all, no doubt, necessary, there are a few specific
"inspection-related" issues which should be examined with respect to
the Scotia experience. These include "blitz" inspections, review of
ventilation plans, and "mine profile rating systems". In terms of
MESA's inspection efforts at the Scotia mine, all three of these
activities were either lacking or seriously inadequate. Rather than
using the "blitz" inspection approach where the entire mine is in-
spected by a team of inspectors — particularly for ventilation and
methane problems — MESA's most common type of Scotia inspections
were one man, spot inspections. As for Scotia's ventilation plan,
MESA's review and evaluation of it was, at best, sloppy. In terms of
a profile of the safety history of the Scotia mine, such a profile was all
MESA's most common health and safety inspection approach
to the Scotia mine involved spot inspections designed to check on
specific and limited conditions in a rather short period of time. Spot
inspections are compared to what MESA calls "regular health and
safety" inspections which are designed to examine the entire mine or
major working portions thereof.
A review of MESA inspection records indicates that from May 1970
to February 1976, MESA conducted 225 spot inspections of the Scotia
mine compared to only 23 "regular" inspections. During this period,
MESA also conducted 113 special hazard inspections and 169 mis-
cellaneous inspections. Prior to the March 9, 1976, explosion, the
last "regular" MESA inspection of the Scotia mine occurred during
an eight-week period in January-February 1976, about a month before
In the opinion of some professionals, spot inspections have very
little overall impact. Elton D. Rea, a highly respected, retired MESA
inspector with considerable experience in gassy mines, told the joint
House-Senate panel, "I am against spot inspections . . all you are
getting is numbers ... It ought to be complete inspections ... If
you are going to make a complete inspection of that mine, it is all
right to spot the mine in between time occasionally ... So I just do
not think that MESA is gaining anything by spot inspections outside
a bunch of numbers to put on the books."
By definition, spot inspections are very limited in both scope and
time. When conducting such inspections, MESA inspectors usually
look for a specific mine condition and have only a few hours in which
to complete the work. The result, unfortunately, is that an inspector
very often will miss hazardous conditions which exist independent of
those he is checking for, and also, his expertise may not be appropriate
for recognizing other hazards. A case in point is Cecil Davis, the
MESA inspector who conducted the inspection of the Scotia mine
less than 24 hours prior to the March 9, 1976 explosion.
During the investigative hearings conducted by MESA, Davis-
who is a respirable dust technician — -was repeatedly questioned as to
why he failed to notice the change in ventilation, and the lack of
proper stoppings. According to the hearing transcript:
Question. Well, Let me ask you this again first. A chock of the ventilation
controls at the intersection (near where the explosion occurred), would that have
a normal part of your inspection that night (March 8th) r
1 ).wis. Xo Sir.
Question. And why would it not have been'.'
Davis. My instructions, you have really got a lot to do if you are evaluating
respirable dust. And all the different aspects that go with this particular type of
inspection. We are instructed that the only thing that we are to be concerned with is
the condition of the section in by the section loading point which is the ta\
Question. Are you saying that when you went up the track through the inter-
section into 2 Left and there was no curtain that ... it would ii"t hav<
part of your inspection to have considered the potential trouble spot up the
Davis. Xo sir. Any outby areas, that is not part of my inspection, any outby
areas. Now, I have instruction from my supervisor, Mr. Herman Lucas, if I
have to spend more than one day on a particular section that I will examine the
p rmissible equipment and go into some of the other aspects of coal mine in-
spections work, if I have to spend more than one day.
Question. You say that your instructions as a technical specialist are that you
don't look at anything outby the tailpiece in the working section?
Davis. This is our instructions.
Question. But by the same token are you not a DAR (Duly Authorized
Davis. Yes Sir.
Question. Is not a DAR required to issue notices for every violation observed?
Davis. Yes Sir.
Question. I just can't quite conceive of a concept that you close your eyes
until you get into the tailpiece?
Davis. No Sir.
Question. You can't rationalize that?
Davis. As I stated in my notes, I observed the roof condition and observed
that areas appeared rock dusted, well rock dusted.
Question. But I think that a check (air curtain) not being there, it should have
been observed and it should have triggered a question in your mind as to how the
straight was being ventilated?
Davis. Well, I hadn't examined any outby area.
From this exchange it is rather obvious that the Davis inspection
was very limited in scope (respirable dust), time (a number of hours)
and approach (Davis was only instructed to inspect a specific mine
area). While Davis did cite the mine for two ventilation violations —
not enough air reaching the mine's face — there were other ventilation
problems that he either did not observe, or was not competent to
recognize; "I am not a ventilation expert" Davis told the MESA
panel. During the MESA hearings, Davis also stated, "As far as
ventilation is concerned, the only part of the ventilation I am actually
interested in is the dust supplement . . ."
There is nothing in the record which demonstrates that the Davis
inspection was very much different from the other 225 spot inspections
that MESA conducted in the Scotia mine. On only 23 separate oc-
casions since 1970 was the mine subjected to an entire examination.
Even in these instances of "regular" health and safety inspections
only one, or perhaps two, MESA inspectors were used. As previously
indicated, there is evidence in the record to indicate that Scotia
personnel, rather routinely, engaged in deceptive practices with
respect to one-man MESA inspections. While an inspector was check-
ing for adequate ventilation, for example, in one section of the mine,
Scotia personnel were robbing air from another section to assure that
the section being inspected was receiving adequate air supplies.
As for MESA Administrator Barrett's plans to conduct "blitz"
inspections, we applaud his initiative. Unlike spot or, for that matter,
"regular" health and safety inspections, we believe that the "blitz"
approach, utilizing teams of MESA inspectors throughout an entire
mine, will serve to make MESA inspections more meaningful and
MESA's review and evaluation oj Scotia's ventilation plans
One of the major issues involved in the Scotia disaster has to do
with the adequacy of the mine's ventilation system. In terms of
MESA's enforcement efforts regarding Scotia's ventilation plan, our
investigation has raised a question as to the adequacy of MESA's
efforts in reviewing and properh' evaluating Scotia's ventilation plan.
To begin with, there is a serious unanswered question as to the
unusual length of time involved in MESA's approval of Scotia's 1976
ventilation plan. Scotia submitted its 1976 plan in January which
MESA neither approved or denied. On March 1, Scotia submitted
another version of its proposed ventilation plan, but as of the date of
the first explosion MESA had taken no action. According to R. Keene,
MESA Mining Engineer for the Pikeville District Office, such a delay
was unusual. Keene told the MESA investigation panel that any
length of time in excess of a month or six weeks for MESA to act on a
proposed ventilation plan was unusual. Thus far we have been unable
to determine why, after nearly 2 l/ 2 months preceding the March 9
explosion, MESA failed to take action on Scotia's proposed ventilation
Another concern we have regarding Scotia's ventilation plan is the
MESA procedures for evaluating and reviewing such plans. According
to MESA mining engineer R. Keene, ventilation plans are approved
on the basis of air quantity figures supplied to MESA by the com-
pany, and then periodically checked by MESA inspectors to deter-
mine compliance. During the MESA investigation hearings Keene
Question. In the ventilation quantities that are reported to you, these quan-
tities are measured by the section foreman or by Mr. Bently or whomever is
making the mine. You do not personally go in periodically and make a check on
the ventilation or quantities in any locations in the mine?
Keene. The plan is approved based on what the Company submits. This
plan is checked periodicall}' by coal mine safety inspectors and the ventilation
To a certain extent, Mr. Keene's contention that the ventilation
plan is periodically checked to determine compliance is substantiated
b} T the record. During the lo-month period prior to the Scotia disaster,
the mine had been cited 18 times for failure to comply with the ap-
proved ventilation plan. However, the record also indicates that it is
extremely difficult for a single MESA inspector to determine full
compliance with the approved ventilation plan. Herschel Potter,
Chief of MESA's Division of Safety, told the Joint House-Senate
panel that the only way to determine the adequacy of a mine's venti-
lation system would be to conduct a complete ventilation sun
"but there is no way that that inspector making an inspection co
have come to that point." The last ventilation survey conducted at
the Scotia mine was in 1974.
A very important example of where the MESA ventilation plan
inspection system broke down can be found in MESA's last "regular"
health and safety inspection of the Scotia mine conducted prior to
the March 9 explosion. During the period January -February 1976,
MESA inspectors spent about eight weeks inspecting the entire
Scotia mine. However, this inspection failed to take notice of the
fact that coal production had been altered in that section of the mine
which subsequently exploded. Prior to initiating production in this
section, 2 Left panel off 2 Southeast main, Scotia, in violation of
MESA regulations, failed to notify MESA of its intentions. Thus,
when production in this section was begun in February, Scotia
violated its ventilation plan and remained in violation of the plan
through the disasters of March 9 and March 11. During the MESA
investigation hearings, MESA mining engineer Keene was questioned
about this development. According to the hearing transcript:
Question. Should you have been notified that 2 Left was begun?
Keene. That is the requirement of the plan; that the projection be shown on
each approved map.
Question. Were you not made aware that they moved into 2 Left?
Keene. When I first became aware that they moved into 2 Left was when they
submitted the map on March 1st.
Question. However, they moved in there roughly around ?
Keene. About a month prior to that date. The section was advanced approxi-
mately four breaks at that time (March 1st). .
Question. Did you consider that a violation of the ventilation plan?
Keene. I would.
The two points we want to make here — in addition to the fact that
the Company violated its approved ventilation plan — are:
1. MESA's eight week "regular" inspection of the Scotia mine
was conducted about the same time that production was started
in the 2 Left section but the inspection failed to uncover the fact
that this production activity violated Scotia's ventilation plan.
2. Keene was aware of the fact that Scotia was in violation of
its ventilation plan on March 1st, eight days before the explosion,
but there is no record of him or anyone else from MESA taking
any action against Scotia for this violation.
Given this experience, we are of the opinion that MESA's review,
evaluation, and enforcement actions vis-a-vis the Scotia ventilation
plan were, at best, sloppy. We question MESA's unusual delay in
taking action on Scotia's 1976 ventilation plan. We question MESA's
policy of accepting company data upon which plans are approved.
We question the adequacy of MESA's inspection and enforcement
actions for determining ventilation plan compliance. There is little
doubt that Mr. Barrett's intentions to more adequately review and
evaluate ventilation plans are absolutely necessary.
Mine Profile Eating System
According to MESA Administrator Barrett, the agency is moving to
fully implement a "mine profile rating system", now in a pilot stage,
"to better pinpoint mining operations for increased enforcement."
Barrett said that in addition to relying on accident injury experience,
the new system also ''takes into account the history and nature of
violations of federal standards at a mine and the health and safety
management system at the mine."
It is very unfortunate that MESA lias waited this long to initiate
such a system. Our review of the entire Scotia record indicates that
MESA's enforcement efforts at the mine failed to include, or even be
effectively cognizant of, the "history and nature of violations of fed-
eral standards at the mine, and the health and safety management
at the mine."
Our research into the Scotia disaster has raised two significant
questions with respect to the use of enforcement information at the
Scotia mine :
1. Whether local MESA officials adequately utilized the infor-
mation they had on the Scotia mine, particularly its history of
2. Whether MESA's national information system was such so
as to bring Scotia- type mines to the attention of top MESA
Based upon what is now known, it must be concluded that local
MESA officials responsible for the Scotia mine did not adequately and
effectively use the information they had on Scotia, and that MESA's
national information system was insufficient in bringing Scotia-type
mines to the attention of top MESA officials.
Based upon the Joint House-Senate Committee hearings, the fol-
lowing has been determined with respect to the use and flow of MESA
enforcement information :
• as with other mines in the area, the history of MESA's enforce-
ment activities at the Scotia mine consisted solely of a collection
of previous inspection reports ;
• local MESA management officials testified that their inspectors
were instructed to review each of the prior inspection reports be-
fore conducting a mine inspection;
• at least one local MESA official testified, however, that inspec-
tors were only required to review the last prior inspection report
before conducting an inspection;
• the local MESA officials were vague as to what use was made
of the inspection information forwarded to the national or re-
gional offices. One such local official said that he "could care
less" what happened to the information once it left the local
• the flow of enforcement related information stopped at the
district or subdistrict office level, thereby never effectively reach-
ing MESA's upper eshelons.
All of these points were succinctly dramatized by Representative
John H. Dent, Chairman of the House Committee on Education and
Labor's Subcommittee on Labor Standards, in his questioning of
MESA officials during the Joint House-Senate hearings. The following
excerpts from the May 13, 1976, hearing provides some insight into
MESA's enforcement information system:
Dent. In asking the question of Mr. Taylor (Ben Taylor, MESA Coal Mine
Inspection Supervisor, Wiiitesburg, Kentucky, office) the Chairman, Mr. Williams,
asked him what disposition was made of the reports of the inspectors. Be said
that he just sent them all up, passed them on through. Then he was asked what
happens to them after they leave his office. He said he could care less . . . Would
it not have been proper and probably essential that he would make son:, 1 notations
on his transmittal and a note for himself stating and adding up these violations
so that someone up above w 11 take a look at them . . . There was no notice
anywhere from anyone t luil we talked to that even had an idea that these violations
were that numerous in any particular month?
Phillips. 'Lawrence Phillips, MESA District Manager. Pikeville. Kentucky,
office) This has already been addressed and Mr. Potter (Herschel Potter. *
<>f MESA's Division of Safety) apologized for Mr. Taylor's comments. Tney do
not reflect our thinking. You talked to the wrong coal mining inspector. The one
under him is Mr. Herman Lucas. The report< are reviewed very, very thoroughly
by him . . .
Dent. (Later in the hearing. Do you up at the top in your position as Chief of
Safety, have a law (regulation) on this particular mine (Scotia) because of its
operation and the multiplicity of violations . . . ?
Potter. An inspection history of every coal mine is available in the field office
from which it is inspected. A copy of that report is sent to the district or sub-
district office . . . The inspectors' instructions are contrary to what Mr. Taylor's
statement was to you. They are to review the inspection history of the mines
prior to making the inspection, look at the ventilation plan, training plans
everything that is supposed to be submitted by the operators prior to making an
inspection. Those inspection reports are not mailed to the Arlington (Virginia)
office (MESA's National Headquarters).
(Later in the dialogue Potter -aid that the data collected nationally) "do-
contain the component history of an inspection that we need to know prior to
making an inspection."
What is particularly revealing about this testimony is that in the
first place, there is confusion on the local MESA level as to how
thoroughly MESA inspectors are to review a given mine's history.
Phillips and Potter said that inspectors were to review the entire
history, while Taylor had previously testified that inspectors were to
only review the last inspection report. In addition, the above testi-
mony clearly indicates that for enforcement purposes all of the perti-
nent information remains at the local level, never reaching top MESA
Another more serious issue — one which is perhaps fundamental to
tliis investigation — is, even if the local MESA officials were completely
aware of Scotia's entire safety history, there is very little evidence to
suggest (hat this knowledge affected MESA's enforcement effort- at
the mine. As this report has shown, MESA's enforcement record at
the Seotia mine was neither progressive nor cumulative in taking
punitive actions against Scotia for repeated, chronic and, we believe,
willful violations of the Coal Mine Health and Safety Act.
If the local MESA management officials were thoroughly aware of
Scotia's history, why did they not more fully use their mine closure
authority, or their criminal sanctions power, or their monetary penalty
authority? If these officials knew of Scotia's safety and health record,
why does the record not show progressively more inspections of the
entire mine rather than a continuation of spot inspections; and if the
inspectors were to carefully review the mine's ventilation plan, why
did the eight-week inspection in January-February 1976 fail to uncover
the fact thai Scotia was violating its ventilation plan? Further, if, as
Mr. Potter suggests, inspectors were to review a mine's employee
training plan, why was it that Scotia was never once cited for failure
to conduct fire 1 and evacuation drills?
It appear- to us that if MESA knew all that should have been known
about the health and safety history of the Scotia Mine, and thus
continued to exercise the kind of enforcement policies that the record
indicates were exercised, then something is very radically wrong with
MESA's overall approach. 11" this analysis of MESA's enforcement
policies al the Scotia mine is even (lose to being correct, and we
believe it is, then the reforms outlined by Mr. Barrett — while no doubt
necessary — simply do not go far enough. We believe that MESA's
enforcement efforts and policies with respect to the Scotia mine were
such that the Company essentially was permitted to ignore the law.
We further believe that the March 9 and March 11 disasters could
and should have been prevented.
Scotia Coal Mine Explosions . . . March 9 and March 11, 1976
While all the causal factors involved in the Scotia disaster have yet
to be determined, enough is presently known about the March 9 and
March 11 explosions to warrant examination and analysis. To
adequately conduct such an analysis, it is useful to examine the events
of March 9 and March 11 in four separate chronological stages:
1. The period from March 8th to the first explosion on March
2. The period between the March 9th and March 11th ex-
3. The period immediately following the March 11th explosion
to the sealing of the mine ;
4. The period from the mine's sealing to the present.
I. PERIOD COVERING THE FIRST EXPLOSION
Based upon our investigation and research, the staff has determined
that there were at least five major issues involved in the first explosion:
1. The nature of the MESA inspection conducted on Mnrch 8th,
less than 24 hours before the first explosion;
2. The nature of the March 9th preshift examination of the
mine by Scotia officials;
3. The ventilation status of that section of the mine where the
explosion occurred (2 Southeast main) ;
4. The possible ignition sources involved in the first explosion;
5. The safety status of the six miners who survived the initial
explosion but who subsequently suffocated to death.
The March 8 MESA Insj^ction.—On March 8, 1976, MESA in-
spector Cecil Davis spent approximately eight hours underground
inspecting the Scotia mine. In terms of the explosion which occurred
the next day, two major questions have arisen with respect to the
1. Was the inspection sufficiently adequate to have uncovered
and corrected the conditions which led to the first explosion?
2. Did Scotia personnel engage in activities designed to deceive
the MESA inspector, particularly in terms of the ventilation
conditions in that general section of the mine which exploded?
While the specific causes of the first explosion have yet to be
determined, there is general agreement that the conditions which
led to the explosion in the 2 Southeast main (2SEM) included an
explosive build-up of methane gas, inadequate ventilation, and an
ignition source. As to whether some of these conditions existed in
2SEM on March 8th, it is not our purpose to either fix individual
blame or to call into question the professional competence of MESA
inspector Davis. However, based on a review of the available evid< n< e,
the staff has concluded that by its very nature, the March 8th MESA
inspection was insufficient so far as the conditions in 2SEM wore
concerned. On the question of deceptive practices, the record contains
evidence of such practices including violations of the ventilation sys-
tem in 2SEM to achieve temporary ventilation compliance with a
MESA notice of violation in the 2 Left panel, off 2SEM.
In terms of the Davis inspection, the record indicates that it was
limited in both purpose and scope. During his testimony before the
MESA investigation panel Davis said that he was a "coal mine
health technical specialist" and his primary job was "concerned
with the evaluation of respirable dust and noise." According to
Davis, his assignment on March 8 was "to begin evaluations (respir-
able dust) of the — all sections of the Scotia, Upper Taggart Mine
in the 'B' seam . . . This would be a complete health (inspection)
of the entire Blue Diamond operations at Oven Fork", (emphasis
added) Davis stated that the geographic focus of his March Mh
inspection was the 2 Left Panel (so-called "tailpiece") off 2SEM.
Except for noticing general mine conditions as he traveled to the
designated area, the only section which Davis inspected was the
2 Left Panel. It is critical to this analysis to note that Davis did not
go into, nor did he inspect, that portion of 2SEM where the explosion
occurred. It should be noted that the 2 Left Panel is adjacent to
2SEM, according to Davis:
My instructions, you have really got a lot to do if you are evaluating respirable
dust. And all the different aspects that go into this particular type of inspection.
We are instructed that the only thing that we are to be concerned with is the
condition of the section inby the section loading point which is the tailpiece
(2 Left Panel).
Davis testified it was not part of his inspection to inspect 2SEM
for ventilation or other possible hazardous conditions. According
to the MESA hearing transcript:
Question. Are you saying that when you went up the track through the inter-
section into 2 Left and there was no curtain (air regulator) that it would not
have been part of your inspection to have considered the potential trouble spot
up the Main (where the explosion occurred)?
Davis. No Sir. Any outby areas, that is not my inspection . . .
While it is obvious that Davis' major concern was respirable dust
conditions in the 2 Left Panel, he did in fact notice other mine con-
ditions, and cited Scotia for a number of violations including:
• Insufficient air reaching the face of the 2 Left Panel (less than
the required 9,000 cubic feet out from the face);
• The line curtain used for directing air to the number 5 entry
working face of 2 Left was more than 10 feet out from the face;
• Eleven water sprays on the continuous miner in the 2 Left
section were inoperable;
• The average concentration of respirable dust was 5.2 milligrams
per cubic meter of air, which was excessive.
From the Davis testimony it is clear that while he conducted a
rather complete examination of the 2 Left Panel, the very limited
nature of his inspection could not have uncovered or corrected any
dangerous conditions in that section of 2SEM which subsequently
Of all the disturbing aspects of the Davis inspection, perhaps the
most disturbing is related to his citation for inadequate air reaching
the working face of the 2 Left Panel, and the deceptive manner in
which Scotia employees '"corrected" the violation. According to
Davis, he issued the insufficient air notice between 3:30 P.M. and
4:00 P.M. When he remeasured the air flow at 6:00 P.M. he found
it adequate at 10,472 cubic feet per minute. Without attempting
to determine how and from where the additional air was obtained,
Davis terminated the notice he had issued two hours before.
Testimony taken at the MESA investigation hearings strongly
suggests that temporary "compliance" with the Davis notice was
achieved by "robbing" air from other sections of the mine and di-
verting it into the 2 Left Panel. According to Merle Rhodes, assistant
mine foreman at Scotia, he was aware that Scotia management
officials were considering erecting temporary curtains to divert more
air from 2SEM into the 2 Left Panel. Rhodes said that lie counseled
against the use of such curtains because they might permit dangerous
concentrations of methane to build-up in the upper portion of 2SEM.
According to the hearing transcript:
Question. You say that you were not aware of nor were you present when
there was discussion regarding the hanging of two checks (curtains) across the
straight (of 2SEM), that is four and five?
Rhodes. The boss asked me about hanging them and I told him not to hang
Question. The boss is?
Rhodes. James Williams (the section foreman).
Question. But you were aware that he was (planning to hang the curtains)?
Rhodes. He didn't say what particular vicinity he was going to hang the
curtains. If he did, I didn't catch it. He was talking about hanging some curtains
and you know I thought that is what he was talking about (hanging them to
divert air) . I told him not to hang it because of the gas accumulating.
Question. But you knew that he was thinking about it?
Rhodes. I know he said he had been told to do it but I don't know whether he
had or not.
The record indicates that Williams, with the assistance of other
Scotia employees, did in fact hang the curtains thereby diverting air
into the 2 Left Panel by interrupting the air flow into 2SEM. Gary
Smith, a Scotia utility man told the MESA panel that he helped
Williams hang the air diverting curtains. According to the MESA
Question. Are you aware that he (MESA Inspector Davis) had taken an air
reading and it was deficient?
Question. After he took the air reading and let the section foreman (Williams)
know that there was a violation, what was done to correct that violation as far
as you know?
Smith We hung block curtains up there (2SEM) in the track at four and five.
Question. Were you instructed to do that?
Question. You were instructed to put up two check curtains?
Question. Across four and five —
Smith. Four and five.
Question. In the main?
Question. You were instructed to do this by whom?
Smith. Bird Dog. Jim is his real name.
Question. Mr. Williams?
Question. Was anyone else present when you were hanging these curtains?
Smith. Yes, Hargus Maggard and Jim (Williams), they helped me.
Question. Were there any others who were aware of the fact that you were
a. Not tight then.
someone aware of it?
Smith. Yes, Carl Smith and Matnack went and took them down. Roy Matnaek.
QUESTION. Mr. Smith, was the inspector aware of what you were doing?
. ; ii. No,
Question. Was there any reason given to you for hanging those che<
Smith. We didn't have enough air. That is what Bird Dog (Jim Williams) said.
And that was good enough.
Thus in terms of the March Sth MESA inspection, the record
indicates that it was conducted by a "coal mine health technical
specialist" whose primary purpose was to evaluate the respirable dust
conditions exclusively in the 2 Left Panel oif 2SEM. The record also
shows that the MESA inspector did not go into that section of 2SEM
where the explosion occurred, and therefore could not have been
aware of any dangerous conditions in that section. In addition, the
record supports the assumption that "something" was wrong with the
ventilation in 2SEM including: the 2 Left Panel, and that Scotia
employees purposefully diverted air from 2SEM into the 2 Left Panel
so as to achieve temporary "compliance" with the Davis violation
notice. In this respect, whatever was technically wrong with the
ventilation in 2 Left Panel was never corrected, and may have been
one of the factors contributing to the March 9th explosion.
March 9 Preshift Examination. — The Coal Mine Health and
Safety Act requires a preshift examination for possible hazardous
ventilation, methane, and other conditions within three hours prior
to any miner entering an active working area of the mine. The Act
also requires that such examinations are to be conducted at least
once a week in those "idle" areas of a mine in which no one is working.
In terms of the March 9th explosion, it has been determined that
the required preshift examination of 2SEM was not conducted, and
that the Scotia official directly responsible for the preshift inspection
falsely signed the inspection records.
Before detailing the nature of the March 9th preshift examination
(fireboss inspection), it is necessary to briefly characterize the status of
2SEM and its 2 Left Panel prior to the explosion. In early February
1976, active mining at the face of 2SEM was temporarily discontinued
because Scotia's existing mining equipment was not adequate to
efficiently mine the high coal face. While the Company awaited the
delivery of the necessary machinery to resume production at the
face of 2SEM, it began production in the 2 Left Panel off 2SEM. As
previously noted, Scotia failed to report this new production to MESA
and thus was in violation of the mine's ventilation plan.
Given the fact that production had stopped at the face of 2SEM,
there is some question as to its preshift examination status. The
Scotia officials directly responsible for the preshift inspection testified
that because production at the face of 2SEM had stopped, the}- con-
sidered that section as "idle" and therefore not requiring the noces^ary
preshifl inspection. However, other Scotia officials testified that they
idered the section "active" and therefore subject to inspection
prior to each shift. In the staff's opinion this latter judgment should
have prevailed because at least a week prior to March 9, a decision was
made to use the upper portion of 2SEM as a storage area for track rails
that were to be used in the section once production at the face resumed.
On the morning of March 9th, two Scotia employees, who were
subsequently killed in the first explosion, were instructed to take the
initial load of track rails into the 2SEM storage area. To move the
rails these men used two locomotive-, one equipped with air breaks
operated by an automatic compressor. By ordering men into 2SBM, all
doubt should have been removed as to the status of the section. 1 1
an active section and should have been properly firebossed before the
men and their locomotives went into the section. As previously stated,
this examination was not made. Also, testimony presented at the
MESA investigation hearings established that the preshift examina-
tion records were falsified.
The two Scotia officials directly responsible for the March 9th pre-
shift examinations were Charles Fields, the third -shift fireboss, and
Arvil Cornett, Scotia's third-shift foreman. From their testimony, and
that of other Scotia officials, the following has been determined:
1. The section of 2SEM which exploded was very seldom fire-
bossed in the weeks immediately prior to March 9th;
2. The section of 2SEM which exploded was not firebossed on
3. The only relevant section firebossed on March 9th was the
2 Left Panel off 2SEM ; and
4. The fireboss records for March 9th, and at other times, were
During the MESA hearings Fields was asked:
Question. Were you in 2 Southeast Mains after the (continuous) miner pulled
out of that section of the mine where the explosions occurred?
Question. How often did you get up there?
Fields. Well not very often.
Question. There were approximately six weeks between the time the equipment
was pulled out of the Mains and moved to 2 Left. . . . How many times would you
say during that five or six week period were you up the mains?
Fields. Really I was up there I would say twice.
When questioned as to whether he had firebossed the 2SEM section
which exploded on March 9th, Fields told the MESA panel, "I didn't
do it." As for Cornett, his testimony indicated that neither did he fire-
boss that particular section. According to the hearing transcript:
Question. On the night before the first explosion, or the morning, I should say,
did you examine the 2 Southeast Mains and the 2 Left section of Southeast mains?
Cornett. I examined the 2 Left section earlier.
Question. Did you examine the Mains?
Cornett. No, I didn't check the mains. I checked the 2 Left panel.
In terms of falsifying the preshift examination records Fields testi-
fied that he regularly signed the "fireboss book" indicating that he had
conducted the required inspections when, in many cases he had not
personally made the inspections for which he signed the book. A case in
point was that Fields signed the" book for the March 9th inspection of
the 2 Left Panel when, in fact, Cornett was the one who made the
examination. According to the MESA hearing transcript:
Question. This (the fireboss book) begins on 3/5/76 and those are the records of
the preshift examinations that were signed for by Mr. Fields prior to the explosions.
Those are your signatures at the bottom of this particular page (for March 9th.)?
You agree they are copies of the fireboss book?
Fields. Yes Sir.
Question. And 3^ou signed for the exams?
Question. But you did not make them?
Fields. No. ►
Question (Later in the hearing). In other words when you made the presbift
exam who and how was the policy established that would allow you to sign th<
for someone else's examination? Was that vour own doing or how was that estab-
>S. Well I have done that ever since 1 have been there.
JTION. And it W&a never called to your attention that that was not accord-
ing to the way it should be? That is that you signed the books? You stated (in the
- that places were ^afe, did not have hazardous conditions. You put measure-
ments into the book. You signed the book. And yet someone else did in fact make
the examination according to your testimony?
From the record it is clear that prior to the two men and their loco-
motives moving into 2SEM nothing was known about the immediate
conditions of the section. The Scotia official who ordered them into
that section — J. P. Feltner, a Scotia construction foreman — testified
that he considered the section as "active" and assumed that it had
been firebossed prior to the men beginning work. Fields and Cornett
stated that they did not know that the two men were going into 2SEM
on March 9th. Richard Combs, Scotia's general service foreman,
stated that while he considered the section "idle", he thought that it
was being firebossed once a week as required. Combs also said that he
and Feltner had talked about using the section to store the track rails,
but he did not know that the men were going into the section on March
9th. Feltner, however, testified that he called Combs on the morning
of March 9th and told him that the work was being carried out.
Out of all this conflicting testimony comes the fact that for whatever
reason, that section which exploded on March 9th had not been
firebossed. As previously noted, the MESA inspection of March 8th
uncovered evidence — which was not fully recognized by the MESA
inspector — that there were ventilation problems in the 2SEM and
2 Left Panel sections of the mine. Unfortunately, it is unknown as to
what conditions would have been found in 2SEM had it been fire-
bossed at least three hours preceding the shift in which the two men
took their locomotives into the section.
Ventilation and Methane in 2 Southeast Main (2SEM). — There is a
general consensus that the conditions which caused the March 9th
explosion in 2SEM included an explosive build-up (5 to 15 percent) of
methane gas, inadequate ventilation, and an unknown ignition source.
With respect to the ventilation and methane conditions in the general
area of 2SEM the following is known:
• coal production in the 2 Left panel off 2SEM violated Scotia's
• a methane gas feeder has been reported near the face of 2SEM;
• ventilation problems were experienced in the 2 Left panel off
2SEM both the (lay before and immediately prior to the explosion;
• Scotia officials engaged in questionable practices to correct the
ventilation problems the day before the explosion;
• the -oct ion of 2SEM which exploded had not been firebossed for
dangerous methane and ventilation conditions prior to the March
9th shift when the two Scotia employees moved into the area with
two locomotives, one of which was equipped with a questionable
Before discussing the above points, a few general observations on
Scotia's ventilation and methane status should be made. First , it should
be noted that there are differences between the Federal and State of
Kentucky's definitions of "adequate ventilation." The Federal Coal
Mine Health and Safety Act describes adequate ventilation as a
minimum of 9,000 cubic feet of air per minute passing over the last
open cross-cut at the face of a mine. The Kentucky Department of
Mines and Minerals, has, however, ruled that due to Scotia's high
liberation of methane, 16,000 cubic feet per minute is required for
safety. According to the record, the Scotia mine, at best, produced
about 10,000 cubic feet of air per minute.
The second observation has to do with the flow of air into the 2SEM
region of the mine. The intake air for this section traveled up the right
side of 2SEM across the face and down the left side of the main to the
2 Left panel. By using air regulating curtains, the air moved up the
right side of 2 Left panel, across its face, down the left side of the panel,
and back out into the 2SEM shaft. What is significant about this air
flow system is that according to Scotia's existing approved ventilation
plan, no air should have been going into the 2 Left panel since Scotia
did not have MESA's approval to be producing coal in the panel.
The third observation is that some of the miners who appeared
before the MESA investigation panel (Carlos Smith, Gary Smith,
and Pat Pate) testified that ventilation in the 2 Left panel was often
poor, and regulating curtains governing the air flow to the face of
2SEM were often moved so as to improve the air in the 2 Left panel.
Arvil Comett, Scotia's third-shift mine foreman, testified that the
quantity of air reaching the 2 Left panel varied greatly, as much as
4,000 cubic feet per minute from one reading to another.
The final observation is simply to note what has been previously
discussed in some detail; the Scotia mine had a long and repeated
history of ventilation violations. From January 1974 to February
1976, the mine was cited for 63 separate violations of federal ventilation
In terms of w T hat is specifically known concerning the ventilation
and methane conditions in the 2SEM and the 2 Left panel at the
time of the explosion, one of the most significant factors is that Scotia
had no business even producing coal in the 2 Left panel. As previously
noted, production in the panel was begun in February 1976, without
informing and receiving MESA's approval. The first anyone from
MESA knew of the new production was on March 1st when Scotia
resubmitted its new ventilation plan. While MESA inspector Cecil
Davis, on March 8, inspected the 2 Left panel, he obviously did not
know that it was in violation of the ventilation plan. To begin pro-
duction in the 2 Left panel, Scotia had to remove a permanent air
stopping which had previously prevented the air in 2SEM from going
into the panel. By removing this stopping and diverting air into the
2 Left panel, Scotia nun" have effectiveiv short-circuited the air in the
In terms of methane gas production it is known that the Scotia mine
was the most gassy mine in Eastern Kentucky, liberating 250,000 to
500,000 cubic feet of gas per 24-hour period. In addition, the record
indicates the prior existence of a methane gas feeder in the floor of
2SEM near the face. Charles Fields, Scotia third-shift fireboss,
testified that he knew of the feeder and had checked it while a<
production was going on at the face of 2SEM, before the 2 Left ;
was opened up. Fields said that when he measured the methane con-
centration at the floor, near the feeder, it registered ; ' percent.
However, when he took the same reading at a level somewhat higher
from the floor, ''it showed nothing." What this indicates is that while
production was continuing at the face of 2SEM, before the 2 Left
panel was begun, the ventilation up 2SEM was sufficient to disburse
any methane being produced. However, once production at the face
of 2SEM was discontinued and begun in the 2 Left panel, the ventila-
tion system was changed. Since Fields only inspected the area ;
during the six-week period prior to the explosion, very little was
known concerning: the methane and ventilation of the upper
section of 2SEM.
If, as the record so indicates, ventilation problems were experienced
in the 2 Left panel, both on the day before and immediately prior to
the explosion, and if, as the record also indicates, Scotia employees
encased in questionable practices to divert more air into the 2 Left
panel by "robbing" air from 2SEM, then methane from the feeder
and other possible sources could have built-up in 2SEM.
Regarding ventilation problems experienced in the 2 Left panel the
day before the explosion, it is known that MESA inspector Davis
issued a violation notice to the effect that not enough air was reaching
the face of 2 Left panel. At approximately 3:45 P.M., Davis measured
the air reaching the face of 2 Left panel and found that it was only
8.092 cubic feet per minute. He issued a notice which was terminated
about 2 hours later when he remeasured the air flow and found it to
be 10,472 feet per minute. iDavis never attempted to determine how
the additional 2,360 feet was achieved. As previously discussed,
Scotia foreman Jim Williams ordered a curtain hung across the 2SEM
shaft thereby interrupting the air flow up the main shaft and diverting
it into the 2 Left Panel, and thereby achieving temporary "compli-
ance" with the Davis notice. Assistant mine foreman Merle Rhodes
testified that he was against the erection of the curtain because of the
danger "of the gas accumulating" in the upper portions of 2SEM.
Once Davis left the mine the curtain blocking 2SEM was taken down.
However, there is nothing in the record to suggest that the ventila-
tion problem uncovered by Davis in the 2 Left panel on March 8,
was ever actually corrected. As a matter of fact, on the morning of
March 9th, ventilation problems were once again experienced in the
2 Left panel. According to testimony, on the morning of March 9th,
at approximately 11:30 A.M., Virgil Coots, the section foreman killed
in the explosion — called James Bentley, Scotia's assistant foreman
responsible for ventilation, and reported that he had "just lost his
air" in the 2 Left panel. Bentley said that he told Coots to check air
curtains. At about this same time the two railmen were moving their
locomotives into the upper portion of 2SEM; the explosion occurred
at approximately 11:35 A.M.
While we do not know the precise conditions which existed in either
the 2 Left panel or the upper portion of 2SEM during the period
immediately prior to the explosion, it is known that the 2 Left panel
suffering ventilation problem-. We also know that the environ-
ment in the upper portion of 2SEM was unknown to anyone, and that
there may have been at least one source liberating methane gas.
From the fact that the explosion occurred at all, it must be assumed
that ventilation in the upper portion of 2SEM was inadequate to
flush out the dangerous concentrations of methane which had to
exist at the time of the explosion.
Possible Ignition Sources. — Perhaps the most significant unknown
factor involved in the March 9th explosion is the source which ignited
the accumulated methane gas in the upper portion of 2SEM. Since
the explosion, a great deal of speculation has surrounded possible
ignition sources. However, given the fact the explosion occurred
minutes after the two Scotia employees moved their locomotives into
the section that exploded, it is reasonable to suggest that the ignition
source was in some way related to this activity. This assumption is
further substantiated by the fact that the mine rescue teams who
recovered the bodies, reported that most of the visable explosion-
related violence in the mine was in the immediate area of the loco-
motives. The teams reported that the battery lids on the locomotives
had been blown off, the mine roof and walls showed evidence of a
violent explosion, and debris w r as scattered throughout the area of
As for the specific ignition source, the speculation has ranged from
the possibility that the men were smoking to the possibility that the
automatic compressor on one of the locomotives fitted with air brakes
caused an electric arc or spark which ignited the methane. Other
possible sources include a spark or arc resulting from a roof fall,
unloading the steel rails, friction from the locomotives, and faulty
electrical equipment or wiring.
Smoking. — Although smoking in a working area of a mine is pro-
hibited by law, it nevertheless does occur. However, in the case of
Scotia, there is no evidence to indicate that smoking caused the
ignition. During the MESA investigation hearings, all those asked
the question stated that they never witnessed anyone smoking in the
Scotia mine. In addition, the rescue teams who recovered the bodies
stated that no smoking materials were found. Also, no evidence was
presented during the investigation hearings to indicate that any of
the victims had smoking materials in their possession.
Roof Fall. — Hocks falling from a mine roof or rib often produce
sparks when they hit steel rails or the mine floor. However, while a
rock fall may have occurred, the circumstantial evidence reported
by the rescue teams indicates the absence of any such occurrence.
Unloading of Steel Rails. — The two men and their locomotives were
in 2SEM to unload and store steel track rails which were loaded on
cars being pushed by the locomotives. There is a possibility that one
or more of these rails may have fallen off the cars or may have been
unloaded in such a way so as to cause an ignition spark. On this
possibility, however, there is no evidence at all.
Friction Sparks from Locomotives. — An ignition spark may have been
created by the wheels of the locomotives and/or their cars if at any time
it become necessary for a quick start or hard stop. Such a spark could
have been caused by the friction of the metal wheels against the metal
track rails. As to this possibility, there is no evidence.
Electricity. — Prior to the first explosion, there were circuits feeding
electricity into the area of 2SEM. During the recovery operations it
was found that fuse boxes in the area had been subjected to intense
heat and may have short-circuited. Another possibility is that an
electric wire may have been looped across the rail tracks and that
the locomotives may have severed the wire causing an ignition spark.
Locomotive and Compressor. — Of the two locomotives taken into
2SEM on the morning of March 9, 1976, one was of a questionable
nature due to the automatic compressor which governed its air brake
system. This particular machine was a Goodman Locomotive initially
purchased in 1942 and subsequently acquired by Scotia. This loco-
motive was originally fitted with hydraulic and manual brakes.
However, the original braking system was inadequate to control the
locomotive on steep grades, and several times at the Scotia mine it
had "run away . . . and imbedded itself in the rib." To improve the
braking system, air brakes were installed on this machine, with a one-
horsepower compressor and an open type pressure control switch.
Thus, the machine automatically monitored the air pressure hi the
braking system and switched on the compressor whenever it was
necessary to maintain the braking pressure; Testimony indicated that
this compressor "kicked on" about cvsvy 15 or 20 minutes. Whenever
the air compressor was engaged the control switch would cause a
substantial arc. The testimony at the hearings unanimously agreed
that the arc caused by the compressor would have been more than
sufficient to ignite an explosive concentration of methane. It should be
noted that due to this type of "open spark" generator, this locomotive
probably should not nave been used in this section of the mine.
Other than the arc created by the automatic compressor there i<
also the possibility that an ignition spark resulted from the batteries
which powered the locomotives, or from some other mechanical
source related to the locomotive.
Given the fact that the second explosion of March 11th occurred
in the same general area as the March 9th explosion, there is some
question as to whether the first explosion ignition source will ever
be conclusively determined. Beyond what is outlined above, any
further analysis of possible ignition sources related to the first explo-
sion must await the reopening of the mine and a thorough scientific
investigation of the physical evidence.
Safety Status of the Six Trapped Miners. — As previously discussed
in this report, six of the fifteen miners killed in the first explosion
survived the initial blast but subsequently suffocated to death. The
record contains professional testimony to the effect that these six
miners, who barricaded themselves in an air pocket near the face of
the 2 Left panel off 2SEM and who suffocated when their self-rescue
breathing apparatus' became inoperable — probably could have saved
themselves simply by walking out of the mine following the explosion.
It has also been determined from the record that Scotia's safety
training program was a "sham" and that fire andf evacuation drills
were nearly nonexistent at the mine. In addition, it has been
determined that there was little if any emergency survival equipment
(e.g., oxygen masks, barricading curtains or rebreathers) stored in
Scotia's underground working areas.
From all of this, it can be assumed that had the six miners been
properly trained in disaster and evacuation procedures, and
they had access to the proper survival equipment, they possibly
could have saved themselves.
II. PERIOD FROM THE FIRST TO THE SECOND EXPLOSION
The first explosion at the Scotia mine occurred at about 1 1 :35 a.m.
on March 9, followed some 60 hours later by a second explosion at
approximately 11:20 p.m. on March 11. Throughout this entire period,
except for a few hours immediately following the first explosion, the
Scotia mine was under MESA's effective control. MESA supervised
the rescue and recovery operations and was responsible for all relevant
decisions and actions, including (he decision to send 13 men into the
mine on March 11, eleven of whom were killed in ihe explosion that
day. Thus, the committee staff believes that if responsibility for the
second tragedy is to be assessed, then that responsibility must resl with
Based upon our research and investigation, it has been determined
that there were at least three major issues involved in the second
1. The environmental status of the mine following the first
2. Possible ignition sources involved in the second explosion.
3. The nature of MESA's decisions between the two explosions.
Environmental Status oj the Mine. — Based upon information ob-
tained from the rescue, recovery and investigation teams that went
into the mine after the first explosion, the following is known with
respect to the prevailing environmental conditions:
• Nearly all the mine damage resulting from the first explosion
was found in the area of the two locomotives located in the upper
portions of 2 SEM;
• Dangerous concentrations of methane and carbon monoxide were
found in 2 SEM;
• Work crews were unable to restore adequate ventilation to 2
• A hazardous roof condition was found to have developed at the
entrance of 2 SEM;
• The upper portions of 2 SEM where the second explosion origi-
nated were not inspected or fire bossed for hazardous conditions.
The rescue teams that went into the mine following the first ex-
plosion on March 9, reported that they observed explosion-related
mine damage in that section of 2 SEM approximately 1,000 feet from
the face. John Collins, captain of the National Mines rescue team,
told the House-Senate Committee that "the entire area was
charred . . . Everything was charred from the fresh air base where we
started, all the way up to the face" (approximately 1,000 feet). In
addition, the rescue teams reported that a number of air stoppings
had been blown out and the battery lids on the two locomotives had
been blown off.
The rescue teams also reported heavy and dangerous concentra-
tions of methane gas and carbon monoxide in the upper portions of
2 SEM. Collins said that the last report his team made from the face
of 2 SEM indicated 5 percent methane, 15 to 16 percent oxygen and
a "CO reading". Collins admitted that the methane concent rati.);:
could have been higher but the measuring equipment only had a
5 percent scale. Other rescue teams confirmed methane readings of as
high as 5 percent and heavy carbon monoxide concentrations. A^
will be discussed more fully below, these methane and CO measuree
merits by the rescue teams, recorded in the early morning hours of
March 10, were the last to be taken in 2 SEM. From the time th-
rescue teams recovered the last two bodies near the locomotives.
nothing more was known about the environmental eonditions in 2
Upon entering the mine on March 9, the rescue teams found that
they could not advance their fresh air base beyond the entrance of
'2 SEM, and had to recover the bodies of the two locomotive men
under self-contained breathing equipment. Following the recovery of
the bodies, attempts were made to restore ventilation to 'J SEM.
On March 10, work crews worked until midnight attempting to
restore ventilation but to no avail. According to William Clemons,
the MESA official in charge of the entire rescue and recovery op
tion, "We could not get air in there (in 2 SEM)".
Also, on March 10, a hazardous roof condition was found to i
at the entrance to 2 SEM. The roof was temporarily supported until
the work crew was withdrawn from the mine at about midnight.
Prior to the first work crew going into the mine on March 10. in
the first attempt to restore ventilation, however, that portion of the
mine where they were to work — not near 2 SEM — had been inspected
and firebossed. Clemons stated, 'Trior to anyone entering the mine
that afternoon (March 10), a fireboss examination was made in the
areas that required such an examination." In addition, a second lire-
boss examination was conducted on the morning of March 11, at 8:14
A.M., prior to the thirteen man work crew entering the mine at 4:15
P.M. later that same da} T . According to MESA Administrator Robert
The MESA and Scotia Coal Company men who began to enter the mine at
8:14 A.M. on March 11, were to examine ventilation controls and to make exami-
nations for hazardous conditions. This is a standard procedure to determine
whether it is safe for men to enter the mine. This in effect was a prc-shift ex;i mi-
nation. These examinations were completed. The examiners determined that the
mine was safe, and a work crew began entering the mine at 4:15 P.M. (emphasis
While it is clear that these two pre-shift examinations did in fact
take place, it is also clear that they were both limited to that portion
of the mine where the two crews were intended to work, which excluded
2 SEM. Ben Taylor told the joint House-Senate Committee, "two
southeast main themselves were not firebossed." Clemons testified
that, "I personally instructed no one to go into two southeast main
..." According to Barrett:
... an examination of the entire mine had been made using company fire-
bosses accompanied by MESA inspectors . . . except for two southeast sections.
Now, that section we had given orders that no one was to go in there — I shouldn't
say no one — they were given instructions that no one was to touch anything
because of the possibility of destruction of evidence. The only people who were in
that section after I left was oar MESA mine rescue team on the night before (the early
morning hours of March 10). (emphasis added.)
Thus at the time the thirteen men entered the mine on March 11,
the environmental status of the 2 SEM was unknown. How T ever, what
was known was that the last reports from the rescue teams on March 9
indicated dangerous concentrations of methane gas in an area where
ventilation had not been restored. As will be discussed more fully
below, there is no indication in the record that any responsible MESA
official adequately considered the possible hazards involved in sending
the thirteen men into the mine on March 11.
Possible Ignition Sources. — As in the case of the first explosion, the
ignition source which caused the second explosion has yet to be con-
clusively determined. However, unlike the first explosion, there is
evidence indicating that the responsible MESA officials failed to
seriously consider at least one possible ignition source that was known
to exist prior to the second explosion — the Goodman locomotive fitted
with an automatic air compressor.
As was discussed earlier in this report, the Goodman locomotive was
one of the two that was sent into the upper portions of 2 SEM on
March 9, immediately prior to the first explosion. The air compr
on this locomotive was an integral part of the machine's braking
system and automatically "kicked on" when the air pressure dropped
below a certain point. According to testimony, the compiv<-or "kicked
on" about every 15 or 20 minutes, and whenever engaged it caused a
substantial arc which was more than sufficient to ignite an explosive
concentration of methane gas. This locomotive-compressor remained
in the mine following the first explosion and remains there today.
In addition, there is no evidence to indicate that the locomotive-
compressor was not operable — kicking on and off — throughout the
period between the two explosions.
The two MESA officials who had the primary responsibility for
considering the locomotive-compressor as a possible ignition source
prior to the second explosion were William demons and Ben Taylor.
Both testified that they were aware of the locomotive-compressor but
never seriously considered it a hazard.
The first of the two to become aware of the nature of the locomotive
was Ben Taylor who, along with Richard Combs (Scotia's general
mine foreman), firebossed a part of the mine on March 10. According
to the Joint House-Senate hearing transcript:
Taylor. (At) some point during this examination (fireboss inspection), during
my conversation with Combs, I became aware that there were air brakes on one
of the locomotives and the air brakes indicated a compressor.
Senator Williams. In other words, you did know there was this compressor
down there, is that right?
Taylor. I became aware of it, yes, during this pre-shift examination.
Williams. Was it discussed that this could be a compressor that comes on auto-
matically? Can it be a site of ignition?
Taylor. I believe we talked about that . . .
Williams. You did?
Later in his testimony Taylor said:
... I never became aware that there was any danger of this compressor . . . there
was idle talk between Combs and I ... I never thought about it again ... it was
something that did not occur in my mind, that it was a danger.
According to Richard Combs, "He (Taylor) said that he understood
that there was a motor in there with a compressor on it, something
about spark, and I said, 'Yes, it's in that area.' "
While Taylor said that he did not give the locomotive-compressor
much thought, he obviously gave the matter some consideration be-
cause the next day, March 11, after the 13 men entered the mine but
at least three hours before the explosion occurred, Taylor told demons
about the locomotive.
As indicated above, Clemons was the MESA official responsible
for directing the entire on-site rescue, recovery and investigation
operations. He assumed that role shortly after the March 9 explosion
and continued in it until sometime after the March 11 explosion. With
respect to the locomotive-compressor issue, demons told the House-
Semite ( Jommittee:
There has been considerable speculation as to what ignited the explosive
methane-air mixture in the second explosion and much of that speculation baa
been focused on the air compressor on the locomotive. In view of this, I consider
ir appropriate for me to disclose what knowledge I had of the compressor. Some-
time during the early evening hours of March 11, 1970, the exact time I cannot
recall, but would estimate it as being between 7:00 and 9:00 P.M. (the explosion
occurred at 11 :20 P.M.), Ben Taylor told me that Richard Combs, Acting Mine
Foreman, during their pro-shift examination on the previous evening, had men-
tioned to him that one of the locomotives in 2 Southeast main was equipped with
air brakes. Mr, Taylor told me that later he started associating air brakes with a
compressor. He then commented that this could have been the cause of the first
explosion. The manner in which Mr. Taylor related the information to me did not
indicate that he was concerned about the situation and did not arouse any concern
on my part. The conversation was very brief and was the first time that I had
heard about the compressor during the 56 to 58 hours since the first explosion. If
it had ever entered my mind, after learning of the percentage of methane and
oxygen present in 2 Southeast main that there was an ignition source present, I
would have immediately withdrawn all men from the mine.
Thus, we have two responsible MESA officials, both coal mine safety
professionals, who were aware of the locomotive-compressor but
neither considered it important enough to fully explore the hazardous
possibilities of it being an ignition source. In his testimony before the
llouse-Senate Committee, MESA Administrator Robert Barrett
admitted that there had been a breakdown in communications during
the period between the two explosions. We agree, and one of the most
critical examples of that breakdown concerned the hazardous nature
of the locomotive as a possible ignition source.
The Nature of MESA's Decisions. — Of the many rescue and recovery
decisions made by MESA in the period between the two explosions
perhaps the two most critical were :
1. The decision to immediately proceed with the investigation
into the causes of the first explosion; and
2. The fateful decision to send the 13-man work crew into the
mine on March 11.
Before detailing the nature of these two decisions, the MESA
decision-making structure at the mine should be noted. As indicated,
the chief operational MESA official responsible for directing the
rescue and recovery operations was William Clemons, Assistant Dis-
trict Manager of the MElSA Pikeville, Kentucky Office. Clemons
assumed responsibility upon arriving at the mine at about 3:15 P.M.
on March 9, and continued in this capacity — with the concurrence
of MESA's top officials including the Administrator Robert Barrett —
until after the second explosion on March 11. During the House-Senate
Committee hearings, Clemons testified that while he had extensive
training in mine rescue and recovery work, he had never before been
involved in the aftermath of a mine explosion. According to the
Williams. Had you ever before directed, or been a part of a rescue-recovery
effort following a mine explosion?
Clemons. No, sir, I have not — I have had extensive training in mine rescue,
and then been a member of a mine rescue team . . .
In terms of his responsibility at the Scotia mine, the following is
Perkins. Who was in charge? Who took over and who was directing the activ-
ities at the mine site after the first explosion?
Clemons. I was directing the rescue and recovery activities.
Perkins. Was there anybody over you?
Clemons. Anybody over me?
Perkins. Giving you orders, or were you in charge of the sole activities there
in making the decisions governing what was to be done?
Clemons. I was making the decisions.
While Clemons was in fact making the decisions at the mine there
were many other MESA officials with whom he conferred and with
whom he cleared his major decisions. These officials included Robert
Barrett — MESA Administrator; John Crawford — MESA Assistant
Administrator; R. Peluso — MESA Assistant Administrator for Tech-
nical Support; Jack Stevenson — MESA Chief of the Ventilation
Group; Monroe West — MESA Sub-District Manager; Charles
Sample — MESA Inspection Supervisor; Ben Taylor — MESA Inspec-
tion Supervisor; Lawrence Phillips — MESA District Manager and
demon's immediate supervisor; W. R. Compton — MESA District
Manager; and Herman Lucas — MESA Coal Mine Inspection
In addition to these MESA officials, others with input into the
decision making process were representatives from the Kentucky
Department of Mines and Minerals, the Scotia Coal Company, and
Scotia miners' representatives.
The decision to immediately begin the investigation into the causes
of the first explosion was taken less than 24 hours after the explosion
was reported. Clemons testified that at about 5:00 A.M. on March 10,
after the bodies had been taken out of the mine, he met with MESA
officials Barrett, Crawford, Pelso, and Compton. At that meeting it
was decided to begin the investigation on March 11, once the necessary
preparatory work had been accomplished. At this time, the damaged
roof condition was unknown and the anticipated work was considered
routine. According to Clemons, "It was my conjecture during the
conference that the exploration work that remained in 2 Southeast
main entries would be only a matter of routine and could be accom-
plished easily without any undue hazards once additional ventilation
was made available . . . the other conferees shared my views ... I
assumed MESA's position of the responsibility for the work of ob-
taining the additional ventilation and exploring the remainder of the
2 Southeast entries so that the area could be made ready for the
Throughout the investigation into the Scotia mine disaster, the
question of "wiry was there such a hurry to begin the investigation"
was never fully addressed. The officials who made the decision knew,
or should have known, that there were dangerous concentrations of
methane in 2 SEM and that the rescue teams had not been able to
restore ventilation in that area. In addition, no one had any idea of
what caused the initial ignition. Given these conditions, the com-
mittee staff believes that the decision to proceed should have been
considered with more caution and as something other than merely
In an attempt to implement MESA's decision to proceed with the
investigation, a work crew, preceded by a fireboss inspection, entered
the mine on the afternoon of March 10. As noted, this crew worked
until midnight attempting to restore the necessary ventilation but
failed. Also, during this time the damaged roof was discovered and the
crew was withdrawn. -
While the initial decision bo proceed with the investigation night
have some justification, it is very hard to find any justification for the
rapidity of the decision to send another work crew back into the mine
on March li. It is also difficult to justify the lack of caution exhil
by MESA in Bending the March 1 1 crew into the mine.
cording to demons, after the March 10th crew had been with-
drawn, he asked Jack Stevenson — a MESA ventilation expert — to
prepare a set of recommendations "as to what was necessary to acquire
additional ventilation in 2 Southeast main." A few hours later,
(lemons held a meeting to discuss future actions, demons told the
House-Senate Committee, "A meeting was held at 2:05 A.M., March
11, 1976, to discuss how to proceed in carrying out Mr. Steve
recommendations . . . This meeting was attended by both MESA
and Scotia Coal Company officials . . ." demons said that based upon
the meeting a tentative plan was developed, calling for a second work
crew to reenter the mine later that day. However, "before leaving the
mine I informed everyone concerned that the plan was a tentative
plan and that no part of it was to be implemented until I discussed it
with my superiors". Clemons stated that he called Assistant Admin-
istrator, John Crawford at about 5:00 A.M. and informed him of the
plan; "Mr. Crawford concurred with the plan as I described it to him."
By 3:00 P.M. that same day, March 11, Clemons had returned to
the mine and found the work crew prepared to enter the mine.
Clemons told the House-Senate Committee that after the crew
entered the mine and began its work without incident, he left the
mine at about 9:00 P.M., leaving Ben Taylor in charge. (At the
time Clemons left the mine he was aware of the locomotive in 2
SEM). Clemons testified that, "At about midnight, just as I was
getting into bed, Mr. Taylor telephoned me that he had unconfirmed
reports of a second explosion."
In terms of the decision to send the crew into the mine on March 11,
the question must be raised as to why was there such a hurry to
proceed and why was such little concern expressed over the possible
hazards of reentering a mine where something was obviously wrong
with the ventilation and where dangerous concentrations of methane
were known to exist? Why did Taylor and Clemons fail to appreciate
the possible hazards of the locomotive-compressor?
While it is impossible to provide definitive answers to these ques-
tions, the questions themselves must be raised. As a possible insight
into the manner in which the decision was made to send the March
11th crew mto the mine, the following exchange between Senator
Williams and Clemons is instructive:
Williams. At the 2:05 A.M. (March 11) meeting . . . did you talk about the
amount of methane that you knew was down there?
Clemons. No sir.
Williams. Did you talk about any agents that might cause a spark?
Clemons. No sir. I am not concerned with methane in itself.
Williams. You know I am surprised. You started (your testimony) when
you first arrived (at these hearings), talking about calculated risk, calculated
risk to go back into the mine. Now, you just said that you did not calculate
any (risk) — you did not put any of these factors into calculating the risk of going
in there with a team.
Clemons. The statement I made about the calculated risk is when you first
go into a mine after a mine explosion.
Williams. Yes, I know that. But now you are — you did not calculate before
sending the working team in there.
Clemons. The exploration that was performed during the initial rescue and
recovery operation did not disclose any fires, did not disclose any smoke, and
this was a pretty good indication to me that there was not an ignition source
Williams. Well now, what was the last reading, the last reading before all
communication was stopped, because there was this second explosion? What was
the last reading on methane and the last reading on carbon monoxide?
Clemons. The last — in two southeast main?
Williams. The last reading that you got out of that mine before you made the
decision at the 2 A.M. meeting to send the team in to bolt the roof? You said
you did not talk about methane and you did not talk about carbon monoxide.
What were the readings that you talked about, that you would have talked about?
Clemons. From the time that the rescue teams had left the locomotives and
recovered those bodies, and the bodies were brought to the surface, there was
no one in by the fresh air base at the mouth of the two left, mouth of two southeast
main. However, a rescue team did go over to the entry and make the methane
and carbon tests.
Williams. That is the only possible reading you get? No one went down by
Clemons. Yes sir.
Williams. It just seems to me that that was the most critical thing to know
before sending people back there to work, what the conditions were with the
information you had.
Clemons. How was I going to determine what the conditions were in by the
fresh air base? I knew I had 4 percent (methane) at the locomotive.
From this dialog it is clear that Clemons, at the time the March
11 tli crew went into the mine, was operating on the same assumptions
he expressed at the March 10 meeting with top MESA officials; that
the work to be done "would be only a matter of routine and could
be accomplished easily without any undue hazards." It should be
noted here that demons' decisions were made with the express and
specific approval of top MESA officials.
Before concluding, one further point should be made with respect
to the period between the two explosions, and that has to do with the
information provided to those 13 men who went into the mine on
March 11. According to the two survivors, Rick Parker and Ernest
Collins, they were never briefed on the conditions in the mine:
Perkins. Let me ask both of you gentlemen who survived . . . were you
advised of the conditions of the mine before you went back in, either of you?
Parker. No, sir, we were not briefed in any way. The only instructions that
were given before we went inside the mine was by Mr. Rick Keene, who told us
to make sure all the electrical supply was off going up into two southeast main,
and also by our mine boss, Mr. Marvin Mangrum, which told us about the work
that we were to perform over two southeast main.
Perkins. You were not briefed in any way?
Parker. No way at all.
Perkins. Why was it that they took people in the mine without briefing them,
people with no experience? (At least one of those killed on March 11, had never
before been underground in a coal mine.)
Collins. I do not know of any.
III. PERIOD FROM THE SECOND EXPLOSION TO
THE SEALING OF THE MINE
The period immediately following the second explosion is character-
ized more by events than issues. As for the decisions and actions taken
during this period, we have no particular quarrel with MESA. Given
the prevailing circumstances and conditions, the committee staff
feels that everything done immediately after the second explosion
was appropriate and reasonable.
Afl noted above, the 13-man work crew entered tlie mine at approxi-
mately 4:15 P.M. on March 1 1. Their assignment included ventilation
restoration work and roof bolting the damaged roof at the entrance to
2 SEM. To accomplish this latter task, a roof bolting machine had to
be moved from another section of the mine to the 2 SEM entrance.
Also, a certain amount of repair work to the roof bolting machine
Of the 13 men, 3 were MESA officials and 10 were employees of the
Scotia Coal Company. According to the testimony of the two sur-
vivors — Rick Parker and Ernest Collins — they had taken the cable
for the roof bolting machine back to connect it to a transformer.
Parker and Collins testified that they were in the process of changing
the plugs on the cable, prior to plugging it into the transformer, when
the explosion occurred at about 11:20 P.M. At the time of the explo-
sion, the survivors were approximately 150 feet from the main work
crew. Following the explosion, Parker and Collins put on their self-
rescue equipment and walked out of the mine. It was on their way
out that they called the surface and reported the explosion. The two
survivors arrived at the surface at about 12:12 A.M. on March 12.
At 1 :00 A.M., MESA's national office in Arlington, Virginia was
notified of the second explosion. Orders were given to airlift MESA
mine rescue teams back to the mine, and to "reactivate MESA's Mine
Emergency Operations Plan." The same mining companies that had
previously sent rescue teams to Scotia responded a second time. Top
MESA officials, including Robert Barrett, left Arlington for the Scotia
mine at 2:20 A.M. and arrived at 5:30 A.M.
According to the testimony of William demons, he was home when
informed of the second explosion at approximately midnight. He
immediately left for the mine, arriving at 1 :00 A.M.
Upon my arrival, I was informed that a second explosion had occurred, that two
men had escaped from the mine and that eleven were unaccounted for. I talked to
the two men who had escaped and got all the information they could furnish me.
From this information, particularly from the extent of the forces, it was obvious to
me that it might be necessary to utilize the air shaft in by 2 Southeast main in the
rescue effort. With this in mind and no present means of entering the shaft, I made
arrangements for mobil cranes to be sent to the shaft. There was a constant in-
crease of CO (carbon monoxide) — from 800 ppm to 2,000 ppm — at the fan which
indicated a strong possibility of a mine fire and caused much concern for a period
of about two hours. I then asked several Scotia Coal Company officials, responsible
officials from nearby coal companies who were present, and several MESA officials
to meet with me for the purpose of discussing the approach we should take in the
rescue efforts . . .
Some felt that the effort should be approached from the shaft and some felt that
we should approach it from the main slope entries. After listening to all their views,
I decided that we would approach it from both directions and that the final
approach would be dictated by the conditions encountered.
According to Clemons, the initial entry into the mine was made by
two MESA officials on foot at the slope entry followed by two rescue
team members. The rescue team members traveled to near the inter-
section of 2 East main before observing any evidence of violence. They
continued up 2 East, about 9 crosscuts, where they discovered that
the ventilation was reversed. The men were immediately withdrawn
from the mine, and two rescue teams were sent to the entrance of 2
East to establish a fresh air base and to make an exploratory investiga-
tion to determine the extent of ventilation damage in the area. These
rescue teams reported that an overcast had been damaged near the
entrance to 2 East and that some 126,000 cubic feet of air per minute
was being short-circuited at that point.
demons stated that based on these reports, it was decided to with-
draw the rescue teams from the 2 East area and to concentrate all
rescue efforts via the air shaft.
Prior to the rescue teams entering the air shaft in the area of 2 SEM,
it had been inspected by MESA, Company, and miner representative
officials. This examination found the ventilation controls intact and the
air flowing in the proper direction and course. Clemons then ordered
the rescue teams to enter the shaft where he briefed them at about 9 :45
A.M. on March 12.
According to Clemons, "Following my instructions closely, the
teams advanced bare-faced to the entrance of 2 Southeast main where
they found the eleven men (approximately 12:00 noon) . . . Since all
eleven were dead, and I had drastic fears of another explosion, I told
the rescue teams to return to the shaft bottom as quickly as possible
(from which they were withdrawn from the mine without recovering
the eleven bodies.)"
According to MESA Administrator Barrett, who had been at the
mine since 5:30 A.M. on March 12, during the remainder of March 12
and on March 13, meetings were held among representatives of mine
management, the Scotia Employees Association, the Kentucky
Department of Mines and Minerals, and MESA, joined by representa-
tives from the Secretary's Office of the Department of the Interior . . .
the consensus decision resulting from these meetings was to seal the
Scotia mine." Thus, on March 19, at 2:10 P.M., all openings to the
Scotia mine were closed.
IV. PERIOD FROM THE MINE SEALING TO THE PRESENT
Since the mine was sealed on March 19, a number of Scotia related
events have transpired including:
• One day of public hearings in Washington, D.C., conducted by
the Senate Subcommittee on Labor on March 24, 1976;
• The convening of a MESA investigation panel which held nine
da}^s of public hearings on April 5, 6, 7, 8, 9, 27, 28, 29, and 30,
1976, in Whitesburg, Kentucky;
• Three days of public hearings conducted by a joint Committee
of the House Education and Labor Committee and the Senate
Labor and Public Welfare Committee on May 7, 1976, in Whites-
burg, Kentucky, and on May 13 and June 16, 1976, in Washing-
• MESA's announcement on June 18, 1976, of tentative plans to
reopen the Scotia mine ; and
• On July 16, 1976, the reopening of the mine was begun.
Throughout this period there have been two issues that have
generated some public controversy:
1. The composition of the MESA investigation panel;
2. The manner in which the 11 bodies are being recovered.
With respect to the composition of the MESA investigation panel,
the following individuals served as members:
• Robert Barrett, MESA administrator, panel chairman;
• Thomas Mascolino, Assistant Solicitor, U.S. Department of
<• Fred Karem, Deputy Undersecretary of the U.S. Department of
• Harrold Kirkpatrick. Commissioner of the Kentucky Depart-
ment of Mines and Minerals;
• George Eadie. Professor of General Engineering:, University of
Til' ° •
• George McPhail, Senior Mine Rescue OfRcer, Province of On-
Of this group, the first factor to be noted is that two of the mem-
bers — Barrett and Kirkpatrick — were directly involved in the events
which occurred at the Scotia mine following the first explosion. It is
not our intention to question the integrity of either man — both are
outstanding professionals in their field — however, the very fact that
they were investigators of events to which they were parties should
be noted for the record. While there is nothing in the record to suggest
that either man conducted himself in a manner detrimental to the
investigation, the fact remains that both, in varying degrees, partici-
pated in the decisions that were made following the first explosion.
The second point to be noted is the glaring absence from the
MESA panel of any miner representatives. Even though the Scotia
mine was, in effect, a non-union mine, the miners who work at the
Scotia mine have a direct and continuing interest in the twin
disasters. It seems to us that a miner representative, at the very
least, would have added to the panel's credibility.
The MESA hearings themselves have been subject to some criticism
by the news media, Scotia miners, and company officials because of
the manner in which they were conducted. The only witnesses to be
called were those selected by MESA and there was little effective
cross-examination by anyone other than the MESA panel.
In terms of the recovery of the 11 bodies that have remained
entombed in the Scotia mine since March 11, the manner in which
they are being recovered is questionable. Following the decision to
reopen the mine, MESA Administrator Barrett assured the families
of the victims that the recovery would proceed as quickly as possible.
Barrett was reported to have initially stated that the recovery would
proceed through the ventilation shaft which enters the mine some 3,000
feet from where the bodies are located. It was estimated that such a
route would enable the bodies to be recovered in about a week.
However, Barrett has reversed himself on the recovery route and
has approved a Scotia Company plan that approaches the recovery
of the bodies through the main shaft. Under this plan, it has been
estimated that the recovery would take a minimum of 60 days. At
the present time reports from the mine indicate that the recovery
operation is confronted with difficulties due to mine flooding.
The point to be made is that by following the Company's plan
the mine will be placed back into production much sooner than if
the recovery took place through the ventilation shaft. Thus, it appears
to the committee staff that MESA — winch still effectively controls
the mine — acquiesced to the Company's production oriented wishes,
rather than insisting on the more humane approach of affording the
families of the eleven men the opportunity of providing their loved
ones with a decent and respectful burial.
SCOTIA COAL MINE-SUMMARY OF VIOLATION NOTICES AND CLOSURE ORDERS, MAY 13, 1970 TO MAR. 9, 1976
1970 1971 1972 1973 1974 1975 1976
Total number of violation notices issued 79 94 156 116 103 214 92
Total number of closure orders issued 6 23 13 24 18 23 3
Total number of 104(a) closure orders issued (imminent
danger) 5 7 4 9 5 9
Total number of violation notices and closure orders 85 117 169 140 121 237 95
Source: Mine Safety Enforcement Administration, U.S. Department of the Interior.
SCOTIA COAL MINE-SUMMARY OF SAFETY AND HEALTH VIOLATIONS, JANUARY 1974 TO FEBRUARY 1976
Total number of—
Category of violation
Ventilation— 30 CFR, pt. 75, subpt. D
Electrica lequipment general— 30 CFR, pt. 75, subpt. F
Combustible materials and rock dusting— 30 CFR, pt 75, subpt F
Fire protection— 30 CFR, pt. 75, subpt. L._
Dust standards— 30 CFR, pt. 70, subpt. B
Trailing cables and grounding— 30 CFR, pt 75, subpts. G and H _
Miscellaneous— 30 CFR, pt 75, subpt. R
Roof support— 30 CFR, pt. 75, subpt. C
Mandatory safety standards, surface coal mines and surface work areas of uhderground
coal mines— 30 CFR, pt 77 _
Maps, hoisting and mantrips— 30 CFR, pt 75. subpts. M and __ _.
Total _ _ 420 39
Source of data: Senate Subcommittee on Labor— Staff Study.
Scotia Coal Mine — Summary of ventilation violations, January 197 J^-F ebruary 1976
Description of violation was cited
Not enough air reaching the working face 26
High methane concentration 7
Approved ventilation plan not being followed 18
Line brattice out of position 6
Methane monitor inoperative 3
Permanent stopping was installed with incombustible material 1
Water sprays not provided for the head drive 1
Fans at new returns section not equipped with a pressure gage and an
automatic signal device to give alarm 1
Tests for methane were not being taken at 20-minute intervals 1
Permanent brattices had not been constructed 2
Lost coal and coal dust 1
Source: Mining Enforcement and Safety Administration, U.S. Department of Interior.
UNIVERSITY OF FLORIDA
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